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DISEASES  OF  NUTRITION  AND  INFANT  FEEDING 


f^^yf^ 


THE  MACMILLAN  COMPANY 

HEW  YORK  ■   BOSTON  ■   CHICAGO   •  DALLAS 
ATLANTA    •   SAN  FRANCISCO 

MACMILLAN  &  CO.,  Limited 

LONDON   ■  BOUBAY   ■  CALCUTTA 
UELBODRNE 

THE  MACMILLAN  CO.  OF  CANADA,  Ltd. 

TORONTO 


DISEASES    OF    NUTRITION 
AND  INFANT  FEEDING 


BY 

JOHN  LOVETT  MORSE,  A.M.,  M.D. 

Professor  of  Pediatrics,  Harvard  Medical  School;  Visiting  Physician  at  the 

Children's  Hospital;  Consulting  Physician  at  the  Infants' 

Hospital  and  the  Floating  Hospital,  Boston 

AND 

FRITZ  B.  TALBOT,  A.B.,  M.D. 

Instructor  in  Pediatrics,  Harvard  Medical  School;  Chief  of  Children's  Medi- 
cal Department,  Massachusetts  General  Hospital;  Physician  to  Chil- 
dren, Charitable  Eye  and  Ear  Infirmary;  Consulting  Physician  at 
the  Lying-In  Hospital  and  at  the  Floating  Hospital,  Boston 


SECOND  EDITION 

REVISED 


THE  MACMILLAN  COMPANY 

1920 

AU  rights  reserved 

.     3  '7  o  S'^ 


CorTBiaHT,  1916. 1920, 

bt  the  macmillajj  company 


Set  up  and  electrotyped.    Publiahed  September,  1911 
Reprinted  October,  1915. 

New  Edition  Completely  Revised  January,  1920 


ne5 


PREFACE  TO  SECOND  EDITION 

The  aim  of  the  second  edition  remains  the  same  as  that  of  the 
first  edition.  New  data  have  been  added  which  brings  the  litera- 
ture up  to  April  1, 1918.  The  exigencies  of  the  war  have  retarded 
investigation  to  such  an  extent  that  during  the  past  year  there 
have  been  very  few  workers  who  were  able  to  do  anything  to  ad- 
vance the  science  of  Pediatrics.  These  recent  publications  have 
not  been  included  in  the  Uterature. 

John  Lovett  Mobse, 
Fritz  B.  Talbot. 
August  6, 1919. 


PREFACE 

This  book  was  written  to  meet  what  seemed  to  the  authors  to 
be  two  distinct  needs  in  American  pediatric  literature;  a  detailed 
description  of  the  scientific  basis  of  rational  infant  feeding  and  a 
description  of  the  method  of  infant  feeding  taught  in  the  Harvard 

J  Medical  School.    In  it  the  authors  have  endeavored  to  meet  these 

\  needs.    It  is  intended  to  satisfy  the  demands,  on  the  one  hand,  of 

those  students  who  wish  to  become  acquainted  in  the  original 

^  with  the  data  on  which  the  scientific  basis  of  infant  feeding  rests 

and,  on  the  other,  of  the  general  practitioner  who  wishes  to  learn 
the  clinical  and  practical  sides  of  infant  feeding.    It  is  hoped  that 

^  it  will  not  only  point  the  way  to  further  investigations  but  also 

^  be  of  service  to  the  clinician  in  his  daily  work. 

I  John  Lovett  Mobse. 

^  Boston,  Fettz  B.  Talbot. 

September,  1916. 


TABLE  OF  CONTENTS 

SECTION  I 

PHYSIOLOGY  AND  METABOLISM 

CHAITEB  page: 

I.  P'hysiology  op  Digestion 1 

II.  The  Digestion  and  Metabolism  op  Fat 20 

III.  The  Digestion  and  Metabolism  op  Carbohydbates   .     .  32 

rV.  The  Digestion  and  Metabolism  op  Protein     ....  43 

V.  The  Metabolism  op  the  Mineral  Salts 68 

VI.  The  Energy  Metabolism  op  Inpants 64 

VII.  Bacteriology  op  the  GASTROiNTESTiNAii  Canal      ...  77 

VIII.  The  Stools  in  Infancy 87 

SECTION  n 

BREAST  FEEDING 

IX.  General  Considerations 99 

X.  Human  Milk:  Chemistry  and  Biology 103 

XI.  Conical  Considerations  and  Techniqxte 134 

Xn.  Wet-nurses 163 

section  m 

ARTIFICIAL  FEEDING 

XlLl.  Cow's  Milk:  Chemistry  and  Biology 167 

XIV.  Cow's  Milk:  Bacteriology  and  Chemical  Tests   .     .     .   175 
XV.  Sterilization,  Boiling  and  Pasteurization  of  Milk  .     .  179 

XVI.  Certified  Milk 189 

XVII.  General  Principles  op  Artificial  Feeding       ....  192 

XVIII.  The  Prescribing  of  Modified  Milk 225 

XIX.  The  Feeding  of  Premature  Infants 250 


X  TABLE  OF  CONTENTS 

♦  SECnON  IV 

DISEASES  OF  THE  GASTROINTESTINAL  CANAL 

CHAPTER  PAGE 

XX.  Spasm  op  the  Pylorus 255 

XXI.  Hypertrophic  Stenosis  op  the  Pylorus 259 

XXII.  Nervous  Disturbances  op  the  Digestive  Tract    .     .     .  267 

XXIII.  Disturbances  op  Digestion 269 

XXIV.  Indigestion  with  Fermentation 291 

XXV.  Inpectious  Diarrhea        302 

XXVI.  Constipation 321 

section  V 

DISEASES  OF  NUTRITION 

XXVII.  Rickets         329 

XXVIII.  Infantile  Scurvy 341 

XXIX.  Spasmophilia 354 

XXX.  Acroosis 361 

Index        369 


DISEASES  OF  NUTRITION  AND  INFANT  FEEDING 


SECTION  I 
PHYSIOLOGY   AND   METABOLISM 

CHAPTER  I 

PHYSIOLOGY  OF  DIGESTION 

MOUTH 

Food  is  drawn  into  the  mouth  of  the  infant  by  the  negative 
pressure  which  results  from  the  act  of  sucking.  This  nega- 
tive pressure  is  between  five  and  fifteen  centimeters  of  mer- 
cury or  between  ten  and  one  hundred  and  forty  centimeters  of 
water.  ^ 

AJmost  all  the  work  on  the  reaction  of  the  oral  cavity  has  been 
done  by  older  writers  and,  although  their  results  have  not  been 
uniform,  it  seems  to  be  established  that  the  reaction  of  the  mouth 
of  the  new-born  infant  is  neutral  or  weakly  alkaline  before  the  first 
food  is  taken.  The  acid  reaction  of  the  mouths  of  older  babies  is 
probably  due  to  the  breaking  down  of  food  remains.  Oshima^  has 
recently  demonstrated  lactic  acid,  by  Uffelmann's  test,  in  the 
mouths  of  infants,  most  often  between  the  ages  of  three  and  six 
months.  He  attributes  the  presence  of  this  acid  to  the  action  of  a 
leptothrix.  It  probably  is  not  present  in  large  enough  amounts 
to  be  of  any  practical  importance.  Immediately  after  birth  a 
baby's  mouth  is  free  from  bacteria,  but  it  very  quickly  becomes 
infected.  The  normal  bacterial  flora,  therefore,  quickly  gain 
entrance  into  the  infant's  gastrointestinal  canal  a  few  hours  after 
birth. 

The  weight  of  the  salivary  glands  at  different  ages,  as  given  by 
Berger,^  is  as  follows: 

^  Gundobin:  Die  Besonderheiten  des  Kindesalters,  Berlin,  1912,  248. 
*Oshima:  Arch.  f.  Kinderh.,  1907,  xlv,  21. 

*  Quoted  by  Gundobin:  Die  Besonderheiten  des  Kindesalters,  Berlin,  1912, 
258. 

1 


PHYSIOLOGY  OF  DIGESTION 


TABLE   1 


Average 

body 

weight 

Parotid 

Av.  wt. 
both  sub- 
maxillaries 
gm. 

Av.  wt. 
both  sub- 
linguals 
gm. 

Age 

Av.  wt. 
gm. 

Max.  wt. 
gm. 

Min.  wt. 
gm. 

New  born 
3  months 
6  months 
2  years 

3580  gm. 
3600  gm. 
4745  gm. 
9100  gm. 

1.80 
3.18 
4.50 
8.60 

2.4 
4.8 
5.8 
9.6 

0.9 
1.4 
3.1 

8.2 

0.84 
1.53 
2.12 
4.89 

0.42 
0.84 
1.05 
2.00 

These  glands  are  heavier  in  healthy  and  well  developed  than  in 
sickly  and  poorly  developed  infants,  but  considerable  individual 
variations  are  often  found.  The  glands  begin  to  differentiate  from 
the  epithelium  of  the  mouth  in  the  second  month  of  fetal  life  and 
can  be  dissected  at  the  tenth  week  of  fetal  life. 

Saliva  is  secreted  during  the  first  week  of  life  and  probably  dur- 
ing the  first  day  (Joerg,  Bidder  and  Schmidt).  It  has  the  power 
of  converting  starch  into  sugar  as  soon  as  it  is  secreted.^-  ^'  ^'  * 
Ptyalin  is  present  in  both  the  parotid  and  submaxillary  glands.^ 
Ibrahim  was  able  to  demonstrate  diastatic  ferments  in  both  the 
parotid  and  submaxillary  glands  of  two  fetuses.  One  of  them 
weighed  but  150  gm.;  the  other  was  in  the  sixth  month  of  fetal 
fife.  He  thought  that  there  was  about  the  same  amount  in  each 
gland  at  birth.  The  diastase  in  the  saliva  is  only  able  to  digest 
starches  as  far  as  maltose  and  not  into  grape  sugar.^*  ^'  ^  Shaw  * 
gave  babies  a  test  meal  of  barley  water  and  washed  out  their  stom- 
achs from  fifteen  to  sixty  minutes  later.  He  found  that  it  was 
possible  for  the  diastatic  action  of  saliva  to  continue  in  the  stomach 
as  long  as  two  hours  after  feeding.  It  is  difficult  to  say  what  rdle 
the  saliva  of  infants  plays  in  the  physiology  of  digestion.  Probably 
it  plays  a  very  small  part.     In  general,  it  has  been  shown,^*  ^^'  ^^• 


*  Schlossmann:  Jahr.  f.  Kinderh.,  1898,  xlvii,  116. 

2  Montague:  Diss.,  1899,  Leiden;  Montague:  Centralbl.  f.  Inn.  Med.,  1900, 
xxi,  705. 

3  SchilUng:  Jahrb.  f.  Kinderh.,  1903,  Neue  Folge,  Iviii,  518. 
<  Moll:  Monatsschr.  f.  Kinderh.,  190&-06,  iv,  307. 

*  Musculus  and  Gruber:  Zeitschr.  f.  Phys.  Chem.,  1878,  ii,  177. 
8  Musculus  and  Mering:  Zeitschr.  f.  Phys.  Chem.,  1878,  ii,  403. 
^Hamburger:  Pfliiger  Arch.,  1895,  Ix,  543. 

*Shaw:  Albany  Med.  Annals,  Jan.,  1904,  xxv,  148. 

*GUnsky:  Sitzung.d.  Gesellsch.  russ.  Arzte  zu.  St.  Petersburg,  1895. 
loWulfson:  Diss.  St.  Petersburg,  1898. 
"Snarsky:  Diss.  St.  Petersburg,  1901. 


PHYSIOLOGY  OF  DIGESTION  a 

^' '  that  the  dryer  the  food,  the  greater  the  secretion  of  saliva. 
This  rule,  however,  does  not  hold  good  with  milk,^  the  food  of 
babies,  because  considerably  more  saUva  is  secreted  for  a  food 
containing  milk  than  for  that  containing  meat.  It  is  admitted,** 
^however,  that  saUva  may  cause  coagulation  of  milk  and  thus 
help  stomach  digestion.  The  amount  of  water,  albumen,  and 
mucus  in  sahva  varies  considerably. 

Finizio  ^  induced  infants  to  suck  bits  of  cotton  and  then  deter- 
mined the  amylolytic  power  of  the  saUva.  This  was  greatest  about 
midday  and  was  different  in  babies  of  the  same  age.  When  the 
babies  were  less  than  six  months  old,  it  did  not  vary  after  nursing 
or  when  starch  was  added  to  the  food,  but  when  they  were  over  six 
months  old,  there  was  an  increase  in  the  amylolytic  power  im- 
mediately after  a  meal  containing  starchy  foods.  This  increase 
was  still  noticeable  an  hour  later.  Beginning  at  about  six  months 
there  seemed  to  be  a  gradual  development  of  the  specificity  of 
function  of  the  salivary  glands.  He  tested  the  sahva  of  several 
babies  monthly  during  the  first  year  and  found  that  the  amylolytic 
power  increased  progressively  from  birth  to  the  age  of  twelve 
months.  At  eight  to  ten  months  it  was  twice  that  at  birth,  and 
at  one  year  a  trifle  less  than  that  of  children  two  to  three  years  old. 
Allaria  "^  found  that,  after  the  first  weeks  of  life,  the  mouth  reacted 
acid  to  litmus  paper  and  phenolphthalein,  and  that  the  reaction 
was  rarely  neutral  or  alkaline. 

STOMACH 

The  stomach  of  the  fetus,  with  the  exception  of  the  pylorus,  lies 
completely  in  the  left  hypochondrium.  The  pylorus  is  in  the 
median  Une  and  is  completely  covered  by  the  liver.  These  rela- 
tions change  after  birth  so  that  at  fifteen  months  the  liver  na 
longer  overlaps  the  stomach.  The  position  of  the  stomach  of  the 
fetus  is  nearly  vertical.  In  the  newly-born  child,  it  hes  some- 
what obhquely  in  the  abdomen,  and  at  the  end  of  infancy,  it  haa 
almost  reached  the  transverse  position. 

The  growth  of  the  fundus  compared  with  that  of  the  stomach  as 

*  Malloizel:  Jour.  d.  Physiol,  et  Pathol.,  gener.,  1902,  547. 
*Heyinann:  Diss.  St.  Petersburg,  1904. 

'Sellheim:  Diss.  St.  Petersburg,  1904. 

*  Billard  and  Dieulate:  Comptes  rend,  de  la  soc.  de  biol.  d  Paris,  1902. 
^Borissow:  Russk.  Wrat.  1903,  Die,  letzen  8  Arbeiten,  quoted  in  Noth- 

nagel's  Handbuch. 

*  Finizio:  Rev.  Hyg.  et  Med.  Infant,  viii,  No.  3,  224. 
^  Allaria:  Monatsschr.  f.  Kinderh.,  x,  No.  4,  179. 


4  PHYSIOLOGY  OF  DIGESTION 

a  whole  is  relatively  rapid  during  infancy.  The  length  of  the 
fundus  of  the  fetus  is  one-fifth,  of  the  infant  one-quarter,  and  of 
the  adult  one-third  of  the  total  length  of  the  stomach.^ 

The  stomach,  as  would  be  expected,  grows  rapidly  in  size  during 
the  first  year.  The  greater  curvature  becomes  longer,  increasing 
16  to  24  centimeters  in  length.  Pisek  and  Lewald  ^  conclude  from 
their  investigations  with  the  Roentgen  ray  that  there  is  no  charac- 
teristic normal  type  of  stomach  in  the  infant.  It  is  horizontal 
rather  than  vertical  when  compared  with  the  adult  type,  and  fol- 
lows certain  rather  definite  forms.  They  distinguished  (a)  the 
ovoid  or  Scotch  bag-pipe  type  of  Flesh  and  Peteri  (b),  the  tobacco 
pouch  (retort  shape  of  Alwens  and  Husler),  and  (c)  the  pear- 
shaped  stomach  with  base  above  and  to  the  left.  The  shape  of 
the  stomach  does  not  depend  on  the  amount  or  character  of  the 
food  ingested,  but  rather  upon  the  quantity  of  gas  which  it  con- 
tains or  acquires.  Major  '  showed  that  the  shape  of  the  Roentgen 
ray  picture  of  the  stomach  varied  with  the  position  of  the  infant 
and  that  the  movements  of  the  diaphragm  could  cause  changes 
in  its  appearance.  Alwens  and  Husler  (quoted  by  Pisek  ^)  report, 
furthermore,  that  they  have  observed  a  change  in  the  form  from 
the  tobacco  pouch  to  the  bag-pipe  variety  after  the  intestines 
have  been  emptied. 

Gastric  Capacily. — Recent  investigations  show  that  the  ana- 
tomic gastric  capacity,  obtained  by  measuring  the  capacity  of  the 
stomach  by  water  poured  in  post-mortem  at  a  pressure  of  15  cm. 
(the  figures  given  in  most  text-books  are  based  on  such  observa- 
tions), is  considerably  smaller  than  the  physiologic  capacity.  The 
physiologic  capacity  of  infants'  stomachs  is  at  such  variance  with 
the  anatomic  measurements  that  it  is  safe  to  say  that  a  baby  can 
digest  more  than  the  anatomic  size  of  the  stomach  would  seem  to 
warrant.^ 

The  following  figures  were  taken  from  Pfaundler,*  and  repre- 
sent the  gastric  capacity  in  cubic  centimeters  post-mortem  with 
a  pressure  of  15  c.  c.  water. 

1  Gimdobin:  loc.  cU.,  264. 

*  Pisek  and  Lewald:  Am.  Jour.  Dig.  Children,  1913,  vi,  232. 
»  Major:  Zeitschr.  f.  Kinderh,,  1913,  viii,  340. 

*  Pisek  and  Lewald:  loc.  cit. 

» Mosenthal:  Arch.  Ped.,  1909,  xxvi,  761. 

•Pfaundler:  Magencapacitat  im  Kindesalter:  Stuttgart,  1898,  quoted  by 
Gundobin. 


PHYSIOLOGY  OF  DIGESTION 


TABLE 

2 

Age  of  infant 

Months 

1 

2 

3 

4 

6 

8 

10 

12 

Systolic  stomach 

150 

175 

210 
200 

235 
230 

290 
295 

360 
365 

430 
445 

4P0 

Diastolic  stomach 

515 

The  gastric  capacity,  determined  post-mortem  by  Holt,^  is  as 
shown  by  Table  3. 

Tables  2  and  3  represent  the  gastric  capacity  of  infants  with 
closed  pyloric  valves  which  allowed  no  food  to  escape  into  the 
intestine.  Mosenthal  investigated  the  gastric  capacity  of  in- 
fants during  life  (physiological  capacity)  and  post-mortem  (ana- 
tomic capacity),  and  fomid  that  the  former  was  always  larger 
than  the  latter. 


TABLE 

3 

Age 

No.  of 

Capacity 

Age 

No.  of 

Capacity 

cases 

oz.           c.  c. 

cases 

oz.     c.  c. 

Birth 

5 

1.2 

36 

7-8  mos. 

9 

6.88 

200 

2   weeks 

7 

1.5 

42 

10-11     " 

7 

8.14 

244 

4 

4 

2.0 

60 

12-14     " 

10 

8.90 

265 

6 

11 

2.27 

68 

8 

4 

3.37 

100 

10 

2 

4.25 

128 

12 

6 

4.50 

132 

14-18  " 

12 

5.00 

150 

5-6  mos. 

14 

5.75 

172 

The  following  table  is  a  summary  of  the  results  which  he  ob- 
tained in  a  study  of  twenty-four  cases: 


TABLE  4 

Amount  of  milk  offered  at  each  nursing 4.0  oz., 

Amount  of  milk  ingested  at  each  nursing 3.6  oz. 

Post  mortem  gastric  capacity  (Kaimdler's  method) 2.6  oz., 


120  c.  c. 

108  c.  c. 

78  c.  c. 


"In  every  instance,  excepting  the  diastolic  stomachs,  the  in- 
fant ingested  more  fluid  at  a  nursing  than  the  volume  of  its  stomach, 
as  determined  by  careful  measurements,  can  contain."  This  means 
that  the  figures  for  gastric  capacity  given  above  represent  the  ana- 


«  Holt:  Dis.  Infancy  and  Childhood,  N.  Y.  and  London,  1911,  309. 


6  PHYSIOLOGY  OF  DIGESTION 

tomic  capacity  of  the  stomach,  and  that  the  physiologic  capacity^ 
what  an  infant  can  take  at  a  nursing,  can  be  considerably  larger 
than  this.  This  can  be  explained  by  the  fact  that  shortly  after 
milk  is  swallowed  the  stomach  shows  signs  of  motor  activity  and 
the  milk  begins  to  pass  almost  immediately  into  the  intestines. 
This  is  proven  by  fluoroscopic  examination  which  shows  the  milk 
spurting  through  the  pylorus  into  the  intestine  before  the  meal  is 
finished.  This  happens  more  easily  with  human  milk  than  it 
does  with  simple  dilutions  of  cow's  milk. 

Duration  of  Stomach  Digestion. — The  duration  of  stomach  diges- 
tion has  been  studied  for  a  long  time,  at  first  with  the  stomach 
tube,^'  ^'  ^'  ^'  ^  only,  and  recently  with  the  Roentgen  ray.®-  ^  It 
can  be  said  in  general  on  the  basis  of  these  observations,  that 
the  stomach  digestion  lasts  in  the  breast-fed  baby  from  one  and  a 
half  to  two  hours,  and  in  the  artificially-fed  baby  three  hours. 
Pisek  and  Lewald  believe  that  a  large  number  of  stomachs  practi- 
cally empty  themselves  within  an  hour,  while  A.  H.  Meyer,^  and 
Von  Monrad  think  that  it  is  three  and  one-half  hours  before  the 
stomach  is  emptied.  A  large  meal  obviously  requires  a  longer 
period  for  digestion  than  a  smaller  one,  and  cow's  milk  remains 
longer  in  the  stomach  than  human  milk.^ 

Ladd's^"  extended  series  of  obser^^^ations  on  babies,  and  Cannon'^'^ 
on  animals,  have  done  much  to  increase  our  knowledge  of  this 
complicated  subject.  The  infant's  stomach,  as  compared  with 
the  adult's,  shows  a  "curious  lack  of  peristalsis."  Shortly  after 
food  is  ingested  some  of  it  may  be  discharged  into  the  duodenum, 
without  undergoing  stomach  digestion.  It  has  been  found  in 
animals  that  carbohydrates  leave  the  stomach  the  most  rapidly 
of  the  three  food  components,  a  large  part  of  them  being  discharged 
within  two  hours,  while  proteins  are  discharged  less  rapidly,  and 
fats  the  most  slowly.  These  facts  fit  in  with  the  economy  of  the 
body,  since  carbohydrates  are  not  digested  at  all  by  the  gastric 
juices,  and  are,  therefore,  passed  along  to  the  small  intestine  as 

^Epstein:  Prager  med.  Wochenschr.,  1880,  45,  450. 
2  Epstein:  Prager  med.  Wochenschr.,  1881,  33-34. 
» Epstein:  Jahr.  f.  Kinderh.,  1887,  xxvii,  113. 
*  Czerny:  Prager  med.  Wochenschr.,  1893,  495,  u.  510   . 
»  Wohlmann:  Jahr.  f.  Kinderh.,  1891,  xxxii,  297. 
«  Tobler  and  Bogen:  Monat.  f.  Kinderh.,  1908-09,  vii,  12. 
^  Leven  and  Barret:  Presse  Medicale,  1906,  63,  503. 
»  Meyer,  A.  H. :  Bibhothek  f .  Laeger,  8,  R,  III,  390-512.    Kopenhagen, 
1902.    Ref.  im  Jahr.  f.  Kinderh.,  1903,  Neue  Folge,  Iviii,  275. 
0  Tobler  and  Bogen:  Monat.  f.  Kinderh.,  1908-09,  vii,  12. 
""Ladd:  Am.  Jour.  Dis.  ChUdren,  1913,  v,  345. 
"  Carmon:  The  Mechanical  Factors  of  Digestion,  London  and  N.  Y.,  1911. 


PHYSIOLOGY  OF  DIGESTION  7 

quickly  as  possible;  whereas  the  proteins,  which  are  digested  by 
the  gastric  juices,  are  retained  for  this  action.  The  fats,  on  the 
other  hand,  are  discharged  from  the  stomach  at  such  a  slow  rate 
that  there  is  never  any  great  accumulation  of  fat  in  the  small 
intestine,  the  rate  of  the  discharge  from  the  stomach  being  ap- 
proximately the  same  as  that  of  the  departure  of  fat  from  the  small 
intestine.  The  discharge  of  mixtures  of  food  depends  upon  the 
relative  proportions  of  fat,  carbohydrate  and  protein  which  they 
contain  (Cannon).  These  findings  in  animals  have  been  partially 
confirmed  in  a  few  observations  on  infants.  In  one  instance,  how- 
ever, in  which  the  infant  received  food  containing  no  fat,  6.62% 
sugar,  and  3.5%  protein,  the  stomach  was  not  empty  at  the  end 
of  l}/2  hours.  If,  however,  a  fresh  feeding  is  given  before  the 
stomach  is  empty,  the  bismuth  feeding  is  frequently  pushed  out 
into  the  small  intestine  by  the  second  meal.  Tobler  and  Bogen  * 
also  found  that  milk  mixtures  containing  much  cream  pass  more 
slowly  through  the  pylorus  than  those  with  low  percentages  of 
fat. 

Gastric  Motility. — The  motility  of  the  stomach  is  in  inverse 
proportion  to  the  concentration  of  the  food;  in  other  words,  the 
greater  the  dilution  of  the  milk,  the  more  rapidly  the  organ  empties 
itself.  ^  Carlson  and  Ginsberg  '  found  that  the  empty  stomach  of 
the  infant  at  birth,  and  of  the  prematurely  born  infant,  exhibits 
the  typical  periods  of  tonus  and  hunger  contractions  of  the  adult. 
They  conclude  that  in  the  normal  mammal  the  mechanism  of 
gastric  hunger  is  completed  physiologically  at  birth  and  is  prob- 
ably active  sometime  before  term.  These  findings  have  been 
recently  confirmed  by  Taylor,^  who  also  concluded  from  his  in- 
vestigations that  there  is  no  appetite  or  psychic  secretion  of 
gastric  juice  in  the  young  infant.  In  animals,  the  stomach  is 
found  to  show  signs  of  motor  activity  shortly  after  milk  has  been 
swallowed.  According  to  the  character  of  the  movements  of  the 
gastric  wall,  two  regions  may  be  distinguished.  The  movements 
of  the  left  hand,  or  cardiac  part  of  the  stomach,  consist  of  slow, 
shallow,  peristaltic  waves,  which  gently  push  the  food  lying  next 
to  the  gastric  wall  toward  the  pylorus.  The  cardiac  part  of  the 
stomach  acts  as  a  reservoir,  where  the  food  lies  undisturbed  by 
any  movement  except  such  as  is  necessary  to  pass  the  peripheral 

» Tobler  and  Bogen:  Monatschr.  f.  Kinderh.,  1908-09,  vii,  12. 

*  Clark:  Am.  Jour.  Med.  Sciences,  May  and  June,  1909,  674,  872. 

•  American  Jour.     Phys.,  1915,  xxxviii,  29. 

*■  Am.  Jour.  Dis.  Ch.,  1917,  xiv,  258;  see  also  p.  254  of  same  for  complete 
bibliography. 


8  PHYSIOLOGY  OF  DIGESTION 

layer  on  to  the  pyloric  half.  The  state  of  affau^  is  different  in  the 
right  half  of  the  stomach.  Five  to  eight  minutes  after  the  ingestion 
of  food,  deep  peristaltic  rings  advance  toward  the  pylorus  and 
press  the  gastric  contents  strongly  against  the  pyloric  valve.  The 
valve  opens  from  time  to  time  and  allows  some  of  the  food  to  pass 
into  the  small  intestine.^'  ^  It  has  thus  been  shown  by  Cannon, 
in  his  Roentgen  ray  work  on  cats,  that  the  two  parts  of  the  stomach 
have  two  distinct  functions,  the  left,  or  cardiac  half,  acting  as  a 
reservoir,  in  which  the  food  lies  practically  undisturbed  until  it  is 
passed  on  to  the  right  or  pyloric  portion.  Here  it  is  thoroughly 
mixed  under  greater  pressure,  and  is  finally  pushed  into  the  small 
intestine. 

Tobler  ^  was  able  to  show,  in  a  boy  with  a  gastric  fistula,  that 
the  coagulation  of  casein  begins  in  from  two  to  three  minutes  and 
is  complete  in  ten  minutes.  This  process  is  of  great  importance, 
since  it  is  found  that  the  fluid  portion,  containing  the  milk  sugar 
in  solution,  is  rapidly  expelled  from  the  stomach,  while  the  curd, 
containing  casein  with  fat  entangled  in  its  meshes,  remains  behind 
for  further  digestion.^  Nature  thus  provides  that  too  much  fat 
is  not  set  free  at  one  time.  The  fluid  gastric  contents  begin 
to  pass  through  the  pylorus  before  the  infant  has  stopped 
nursing. 

The  cardiac  end  of  the  stomach  has  a  very  delicate  mechanism 
of  its  own  by  means  of  which  it  is  at  times  closed,  at  others  open. 
In  cats  the  cardia  is  alkahne.  As  soon  as  it  becomes  acid,  the  car- 
diac orifice  closes  and  remains  so  until  the  neighboring  food  com- 
ponents become  alkaline.^  The  pyloric  valve  acts  in  a  manner 
directly  opposed  to  that  at  the  cardia.  When  the  material  in  the 
antrum  pylori  is  acid,  the  valve  opens  and  vice  versa*. 

On  the  duodenal  side  of  the  pyloric  valve  an  alkaline  reaction 
allows  the  valve  to  open  and  an  acid  reaction  causes  it  to  close. 
Cowie  and  Lyon ''  found  that  the  opening  and  closing  reflex  of  the 
pyloric  valve  could  also  be  demonstrated  in  infants.  When  the 
food  was  made  acid  the  duodenal  closing  reflex  is  sustained  and 
the  evacuation  of  food  from  the  stomach  is  consequently  delayed, 
,  even  if  the  stomach  contents  are  acid.  Strongly  alkaline  food,  on 
the  other  hand,  causes  the  pyloric  opening  reflex  to  be  delayed 

1  Cannon:  Am.  Jour.  Phys.,  1898,  I,  359. 

=*  Cannon:  Am.  Jour.  Med.  Sciences,  1906,  cxxxi,  563. 

» Tobler:  Verhandl.  d.  Gesell.,  Kinderh.,  1906,  xxiii,  144. 

*Moritz:  Zeitschr.  Biol,  1901,  xlii,  565. 

6  Cannon:  Am.  Jour.  Phys.,  1908,  1909,  xxiii,  105. 

*  Cannon:  Am.  Jom-.  Med.  Sciences,  1906,  cxxxi,  563. 

^  Cowie  and  Lyon:  Am.  Jour.  Dis.  Children,  1911,  ii,  262. 


PHYSIOLOGY  OF  DIGESTION  9 

and  as  a  result  the  food  is  retained  longer  in  the  stomach.  Free 
hydrochloric  acid  is  not  necessary  for  pyloric  opening  in  the  in- 
fant, and  it  may  provoke  prolonged  closing  from  the  duodenal 
reflex. 

Solid  particles  of  food  may  be  pushed  against  the  pylorus  with- 
out opening  the  valve  ^  and  it  is  supposed  that  the  curd  of  milk  wiU 
have  considerable  mechanical  influence  on  the  opening  and  closing 
of  the  pylorus,  while  fat,  whey,  and  lactose  have  httle  or  no  me- 
chanical action.  Tobler  *  has  also  shown  that  the  rapid  inflation  of 
a  balloon  in  the  duodenum  checks  the  passage  of  food  from  the 
stomach.  Cannon  ^  believes  that  the  evidence  is  opposed  to  the 
conception  that  mechanical  agencies,  acting  either  in  the  stomach 
or  in  the  intestine,  play  an  important  part  in  controlling  the 
normal  gastric  evacuation. 

Influence  of  Posture  on  Digestion  and  Emptying  Time  of 
Stomach. — Owing  to  the  anatomical  position  of  the  cardia,  air 
which  is  swallowed  while  nursing  is  prevented  from  escaping  from 
the  stomach  while  the  infant  is  in  the  horizontal  position  because 
food  acts  as  a  water  valve.  The  air  can  escape  if  the  infant  is 
upright  and,  therefore,  it  is  better  to  hold  the  baby  upright  after 
nursing  or  during  nursing.  Distension  with  air  causes  discomfort, 
prevents  the  infant  from  taking  the  proper  amount  of  food  and 
causes  vomiting.^ 

Fluroscopic  examination  of  the  stomach  shows  that  the  emptying 
time  is  markedly  influenced  by  the  position  of  the  infant.  There 
is  comparatively  slow  motihty  in  the  supine  position,  and  the 
stomach  empties  much  more  rapidly  when  the  infant  is  on  the 
right  side  than  when  it  is  on  the  left  side.  This  phenomenon, 
which  is  almost  constant,  would  seem  to  have  clinical  signifiance. 
It  should  prove  to  be  of  advantage  to  place  infants  on  the  right 
side  when  there  is  an  evident  delay  in  gastric  digestion.^ 

Secretion  of  the  Stomach. — Pepsin  has  been  found  in  the 
stomachs  of  fetuses  bom  at  four  and  six  months,^'  *  and  is  always 
present  in  the  stomachs  of  babies  bom  at  term.'   Breast-fed  babies 

1  Tobler:  Zeitschr.  Physiol.  Chem.,  1905,  xlv,  185. 

*  Cannon:  The  Mechanical  Factors  of  Digestion,  London  and  New  York, 
1911. 

» Smith  and  Le  Wald,  Am.  Jour.  Dis.  Ch.,  1915,  xi,  261. 
*Hess:  Am.  Jour.  Dis.  Ch.,  1915,  ix,  461;  De  Buys  and  Henriques:  Am. 
Jour.  Dis.  Ch.,  1918,  xv,  190. 
'Langendorff:  Arch.  f.  Anat.  u.  Physiol.,  1879. 

•  Huppert:  Wiener  Sitsungsberichte,  81,  Abt.  3. 

^  Zweifel:  Untersuchungen  iiberden  Verdauungsapparat  der  Neugeborenen, 
BerUn,  1874. 


10  PHYSIOLOGY  OF  DIGESTION 

secrete  less  pepsin  than  artificially-fed  babies.  Rennin  is  prac- 
tically always  present  at  birth. ^  There  is  no  appetite  or  psychic 
secretion  of  gastric  juice  in  the  young  infant.^  Heubner  ^  found 
lactic  acid  in  babies'  stomachs,  but  Sotow  "*  and  Hamburger  and 
Sperk  were  imable  to  confirm  these  findings.  A.  H.  Meyer  ex- 
plained these  conflicting  results  when  he  found  that  lactic  acid 
appeared  within  two  hours  after  the  feeding  of  mixtures  of  cow's 
milk,  and  that  it  never  appeared  after  a  test  meal  of  tea,  or  a 
"water  meal."  This  makes  it  practically  certain  that  the  lactic 
acid  found  in  the  stomach  is  not  the  result  of  gastric  secretion, 
but  of  the  action  of  the  stomach  juices  or  of  bacteria  on  the 
food. 

Engel  ^  studied  an  infant  of  four  weeks  with  a  fistula  in  the 
upper  duodenum,  in  which  the  connection  between  the  stomach 
and  duodenum  was  apparently  cut  off.  The  infant  received  noth- 
ing by  mouth.  Engel  was  able  to  collect  from  100  to  200  cubic 
centimeters  of  gastric  secretion  per  day  by  means  of  a  small  rubber 
tube  passed  through  the  mouth,  and  found  in  this  pepsin,  rennin, 
and  free  hydrochloric  acid.  He  was  unable  to  demonstrate  a  fat- 
splitting  ferment  or  lactic  acid.  There  is  a  difference  of  opinion 
concerning  the  presence  of  fat-splitting  ferments  in  the  stomach  of 
infants  from  birth  onward.  Sedgwick  ®  removed  the  stomach  con- 
tents and  fouud  that  they  were  able  to  split  fat.  This  property  is 
present  at  birth  in  rabbits  and  at  a  very  early  age  in  babies  (in  one 
case  at  two  weeks).  Hess  ^  found  lipase  in  the  stomach  of  the  un- 
fed new-born  infant.  As  much  as  25%  of  the  fat  in  the  food  can  be 
split  by  the  gastric  juices,  although  it  is  believed  that  under  normal 
conditions  less  than  this  is  split.  In  infants  between  one  and  four 
months  old,  the  lipase  content  of  the  stomach  increases  with  the 
age  of  the  infant.  ^  Gastric  lipase  is  easily  destroyed  by  free 
hydrochloric  acid  0.2%.^ 

Kramsztyk  ^°  found  trypsin  in  a  small  proportion  of  the  infants 
to  whom  oil  test  meals  had  been  given.     It  is  believed  that  this 

^  Hamburger  and  Sperk:  Jahr.  f,  Kinderh.,  1905,  Neue  Folge,  Ixii, 
495. 

2  Taylor:  Am.  Jour.  Dis.  Ch.,  1917,  xiv,  258. 
^  Heubner:  Jahr.  f.  Kinderh.,  1891,  xxxii,  27. 
<  Sotow:  Diss.  St.  Petersburg,   1895. 

5  Engel:  Archiv.  f.  Kinderh.,  1909,  xlix,  16. 

6  Sedgwick:  Jahr.  f.  Kinderh.,  1906,  Ixiv,  194;  also.  Arch.  Ped.,  1906. 
^Hess:  Am.  Jour.  Dis.  Children,  1913,  vi,  264. 

«  Hahn:  Am.  Jour.  Dis.  Children,  1914,  vii,  305. 
» Hull  and  Keeton:  Jour.  Biol.  Chem.,  1917,  xxxii,  127. 
»"  Kramsztyk:  Przeglad  Pedyatryczny,  1909,  i,  209. 


PHYSIOLOGY  OF  DIGESTION  11 

tryspin  has  its  origin  in  the  pancreas  and  is  regurgitated  into  the 
stomach.    (Ibrahim.) 

Practically  all  of  the  factors  present  in  the  adult  digestion  are 
present  in  babies,  but  in  a  weaker  form. 

Free  Hydrochloric  Acid. — Free  hydrochloric  acid  is  never  found 
in  the  stomachs  of  some  healthy  breast-fed  infants  ^  while  in  others 
it  is  found  regularly.^  Hess  ^  found  it  regularly  in  the  stomachs 
of  new-bom  infants  even  before  food  was  given.  Whether  free 
hydrochloric  acid  is  found  or  not  in  a  given  instance  seems  to 
depend  upon  the  technique  of  the  investigator.  It  may  be  said, 
in  general,  that  the  longer  after  a  meal  the  stomach  contents  are 
tested,  the  more  frequently  hydrochloric  acid  is  found.  It  is  ob- 
vious that  when  a  baby  receives  a  food  containing  much  casein, 
free  hydrochloric  acid  will  appear  much  later  than  when  it  receives 
a  food  which  contains  but  little  casein  or  other  material  with  which 
hydrochloric  acid  can  combine. 

Dundin  ^  found  that  the  reaction  of  the  gastric  mucous  mem- 
brane of  the  fetus  was  always  neutral  up  to  the  sixth  month, 
after  which  it  was  acid.  He  was  unable,  however,  to  demonstrate 
free  hydrochloric  acid  in  any  fetus.  Hamburger  and  Sperk  ^ 
found  small  amounts  in  the  stomachs  of  new-bom  babies  from 
the  third  to  the  eighth  day.  The  amount  increases  with  the  age 
of  the  baby  (A.  H.  Meyer).  About  three  times  as  much  becomes 
"combined  acid"  on  artificial  feeding  as  on  breast  feeding.  The 
acidity  immediately  after  a  meal  is  nil,  but  steadily  increases  dur- 
ing digestion,  the  rapidity  of  the  increase  varying  directly  with 
the  age  of  the  child.  Free  hydrochloric  acid  appears  in  a  few  min- 
utes after  a  feeding  of  barley  water.  It  does  not  appear,  however, 
for  an  hour  or  more  after  a  feeding  of  milk,  the  delay  being  due 
to  the  power  of  casein  to  absorb  and  combine  with  acid.  Free 
acid  appears  later  in  disease  than  in  health.^  It  is  interesting  to 
note  that  the  breaking  down  of  sugar  into  lactic  acid  is  retarded 
by  the  presence  of  from  .01%  to  .02%  of  hydrochloric  acid  and 
prevented  by  .07%  to  .08%.  The  power  of  casein  to  delay  the 
appearance  of  free  hydrochloric  acid  explains  the  fact  that  lactic 

^Heiman:  Arch.  Ped.,  1910,  xxvii,  570;  Labb6:  Rev.  mens.  d.  mal.  de 
I'enfance,  1879,  xv,  401. 

*Cassel:  Arch.  f.  Kinderh.,  1890,  xii,  175;  Wohhnann:  Jahrb.  f.  Kinderh., 
1891,  xxxii,  297. 

•Hess:  loc.  cU. 

*  Dundin:  quoted  by  Gundobin,  Die  Besonderheiten  des  Kindesalter, 
BerUn,  1912,  269. 

'  Hamburger  and  Sperk:  Jahrb.  f.  Kinderh.,  1905,  Ixii,  495. 

^  Clark:  Am.  Jour.  Med.  Sciences,  May  and  June,  1909,  672,  872. 


12  PHYSIOLOGY  OF  DIGESTION 

acid  is  frequently  present  in  the  stomachs  of  babies  fed  on  cows* 
milk.^'  2-  3 

The  recent  studies  of  Hahn  ^  of  the  hydrogen-ion  concentration 
of  the  gastric  contents  have  added  light  from  another  point  of 
view.  He  found  that  the  acidity  of  the  stomach  juices,  when  stud- 
ied in  this  manner,  was  strikingly  constant  being  (H)  =  1.0  X  10~^. 
This  is  in  striking  contrast  to  the  figures  given  above  of  the  titrable 
acidity,  and  is  considered  to  be  the  normal  acidity  of  the  stomach 
contents  at  the  height  of  digestion,  when  the  food  is  either  one- 
third  or  two-thirds  milk.  He  beUeves  that  this  is  the  optimum 
acidity  for  the  action  of  rennet  and  gastric  Upase  and  that  it  in- 
hibits the  action  of  pepsin. 

Our  conception  of  the  therapeutic  action  of  alkalies  in  modifying 
gastric  digestion  has  recently  been  changed.  It  has  been  claimed 
by  Southworth  ^  and  others,  on  the  basis  of  the  work  of  Van  Slyke 
and  Hart,  that  lime  water  and  sodium  bicarbonate  neutralize  the 
hydrochloric  acid  secreted  in  the  stomach,  and  thus  delay  the 
coagulation  of  milk  by  rennin.  As  the  result  of  this  delay  a  por- 
tion of  the  milk  is  allowed  to  pass  into  the  duodenum  before  co- 
agulation takes  place.  The  amount  of  alkali  given  should  be  cal- 
culated in  relation  to  the  amount  of  milk  and  cream  used  in  the 
mixture  and  not  to  the  total  quantity  of  the  mixture,  because  the 
milk  and  cream  alone  contain  casein  and  it  is  the  casein  which  is 
acted  upon  by  the  rennin.  This  seems  to  be  the  most  reasonable 
view  to  take  at  present.  Clark  ^  claims,  however,  that  lime  water 
does  not  reduce  the  acidity  of  the  gastric  contents,  and  that  the 
neutralization  of  a  portion  of  the  acid  is  overcome  by  an  increased 
stimulation  of  the  gastric  glands  to  form  hydrochloric  acid.  The 
amount  of  acid  available  for  digestion  may  thus  be  even  increased. 
These  findings  presumably  apply  also  to  bicarbonate  of  soda.  The 
evidence  in  relation  to  this  subject  is  conflicting  and  it  is  by  no 
means  certain  that  the  present  conception  of  the  action  of  alkalies 
will  not  be  greatly  modified  by  future  investigations.  The  action 
of  sodiiun  citrate  has  recently  been  shown  by  Bosworth  (see 
chapter  on  Chemistry  of  Cow's  Milk)  to  be  dependent  in  large 
part  on  reactions  that  occur  in  the  milk  itself.  It  changes  the 
compound  known  as  calcium  caseinate  into  sodium  caseinate. 
Sodium  caseinate  is  changed  by  rennin  to  sodium  paracaseinate, 

^  Sieber:  Nad.  Jour.  f.  prakt.  Chemie,  1879,  xix,  433. 

'Cohn,  F.  O.:  Zeitschr.  f.  Phys.  Chem.,  1890,  xiv,  75. 

3  Hirschfield:  Pfluger  Arch.,  1890,  xlvii,  510. 

*  Hahn:  Am.  Jour.  Dis.  Ch.,  1914,  vii,  305. 

» Southworth:  Arch,  of  Pediatrics,  Feb.,  1905,  p.  131. 

6  Clark:  loc.  cit. 


PHYSIOLOGY  OF  DIGESTION  13 

which  is  soluble,  while  calcium  paracaseinate,  which  is  formed 
from  calcium  caseinate,  is  insoluble.  Coagulation  by  rennin  is 
thus  prevented.  To  what  extent  sodium  citrate  may  also  com- 
bine with  the  hydrochloric  acid  of  the  stomach  to  form  sodium 
citrate,  and  thus  reduce  the  amount  of  "available  hydrochloric 
acid,"  is  unknown. 

Rennin:  (Chymosin). — ^The  rennin  ferment  has  been  foxmd  in 
the  stomach  on  the  first  day  of  life.*  It  causes  the  coagulation 
of  milk.  It  is  in  the  form  of  a  pro-ferment  in  the  gastric  mucous 
membrane,  which  is  inactive  until  it  has  come  into  contact  with 
hydrochloric  acid.^  According  to  Hahn  '  it  works  best  with  a 
hydrogen-ion  concentration  (H)  =  l.Ox  10"^.  Some  writers,"**  ^ 
believe  that  rennin  and  pepsin  are  identical,  because  it  has  been 
impossible  to  separate  the  two  enzymes  by  obtaining  specific  anti- 
bodies for  them.  There  is  not  sufficient  evidence  available  to 
settle  this  question. 

Pepsin. — Pepsin  has  been  extracted  from  the  gastric  mucous 
membrane  of  a  four  months'  old  fetus  ^  and  is  usually  present  at 
all  ages  in  both  health  and  disease.''  Healthy  breast-fed  infants 
seem  to  produce  less  than  healthy  artificially-fed  infants  of  the 
same  age.  The  amount  increases  from  birth  until  the  end  of  the 
third  month  of  life,  after  which  it  remains  constant.  Older  babies 
of  less  than  the  normal  weight  produce  the  amount  of  pepsin  which 
corresponds  to  their  ages.*  The  stomachs  of  babies  with  severe 
chronic  disturbances  of  nutrition  frequently  contain  no  pepsin. 
When  these  babies  improve  in  health  and  gain  in  weight,  their 
stomachs  again  contain  pepsin.  The  stomach  juice  of  normal  in- 
fants is  capable  of  transforming  protein  into  peptone.^'  ^^  Pepsin 
is  present  in  the  gastric  glands  as  pepsinogen  (Glassner),  which 
is  converted  by  hydrochloric  acid  into  pepsin.  An  hydrochloric 
acid  extract  of  the  gastric  mucous  membrane  quickly  loses  its 
power  of  peptonization  when  the  acid  is  neutralized  with  soda. 

Absorption  in  the  Stomach. — Most  of  the  direct  experiments 
on  gastric  absorption  have  been  done  on  animals  and  indirect 

iSz'dlowski:  Jahrb.  f.  Kinderh.,  1892,  xxxiv,  411. 
*GIaessner:  Beitr.  z.  chem.  Physiol,  u.  Path.,  1902,  i,  24. 
'  Hahn:  Am.  Jour.  Diseases  of  Children,  1914,  vii,  305. 

*  Pawlow  and  Parastschuk:  Zeitschr.  f.  Physiol.  Chemie,  1904,  xlii,  415. 

»  Blum  and  Boehme:  Hofm.  Beitr.  z.  chem.  Physiol,  u.  Path.,  1907,  ix,  74. 

•  Langendorff :  Arch.  f.  Anat.  u.  Physiol.,  1879,  95. 
'Clark:  loc.  at. 

*  Rosenstern:  Berliner  klin.  Woch.,  1908,  xlv,  542. 

•  Ramsey:  Arch.  Ped.,  May,  1909,  341. 

"  Langstein:  Jahr.  f.  Kinderh.,  1906,  Neue  Folge,  bdv,  139. 


14  PHYSIOLOGY  OF  DIGESTION 

methods  have  to  be  depended  upon  in  babies.  Pfannenstill  * 
found  that  iodine  appeared  in  the  urine  of  healthy  breast-fed  babies 
in  from  fifteen  to  twenty-five  minutes  after  it  was  given  by  mouth. 
These  results  have  been  confirmed  by  other  observers.  Gundobin  ^ 
found  that  the  absorptive  power  of  the  stomach  (for  KI)  was 
diminished  in  disease  in  direct  proportion  to  the  severity  of  the 
disease.  For  example,  in  "dyspepsia"  potassium  iodide  was  ab- 
sorbed on  the  average  in  17.1  minutes,  in  "gastroenteritis"  in  24.5 
minutes,  and  in  "cholera  infantum"  in  34.9  minutes.  According 
to  Cannon  ^  absorption  is  an  associated  function  of  the  churning 
action  in  the  vestibule  of  the  stomach.  "Although  water  is  not 
absorbed  in  the  stomach,  glucose  in  concentrated  solution,  and 
proteins  which  have  been  expossed  to  gastric  digestion,  may  be 
absorbed  in  considerable  amount  (V.  Mering  and  Tobler).  The 
mucosa  of  the  vestibule  has  fewer  glands  than  the  muscosa  of  the 
cardiac  end,  where  they  are  placed  in  very  close  order.  The 
absorption  that  occurs  in  the  stomach  probably  takes  place,  there- 
fore, in  the  vestibule,  for  there  the  epithelial  surface  is  most  favor- 
able to  the  process.  There  also  gastric  digestion  is  most  advanced, 
and  the  food  in  consequence  is  most  ready  for  passage  through  the 
mucosa.  Furthermore,  the  mechanical  conditions  in  the  vestibule 
are  most  favorable  to  absorption  because  the  digested  food  is  re- 
peatedly brought  into  very  close  contact  with  the  mucous  lining." 

PANCREAS 

The  weight  of  the  pancreas  increases  in  general  parallel  with 
the  body  weight.  Taking  average  figures,  the  increase  of  weight 
in  intra-uterine  life  is  relatively  rapid,  so  that  it  is  forty  times 
larger  at  birth  than  it  is  at  the  third  month  of  fetal  life.  After 
birth  it  doubles  in  weight  in  from  three  to  four  months,  at  the 
same  time  increasing  its  functional  activity  proportionately.  The 
increase  in  weight  from  this  time  on  is  slower. 

The  table  of  Hartge  ^  on  page  15  (Table  5)  gives  the  weights 
and  measurements  of  the  pancreas: 

The  pancreatic  secretions  contain  three  digestive  ferments, 
namely,  trypsin  which  splits  up  protein,  amylopsin  which  changes 
starch  into  sugar,  and  steapsin  which  spHts  neutral  fat  into  fatty 

1  Kannenstill:  Nord.  med.  Archiv.,  1892,  Neue  Folge,  ii,  Heft  10. 

*  Gundobin:  Die  Besonderheiten  des  Kindesalters,  Berlin,  1912,  272. 

*  Cannon:  The  Mechanical  Factors  of  Digestion,  New  York  and  London, 
1911,  68. 

''  Hartge:  The  Pancreas  of  the  Foetus  and  Newborn:  Diss.  St.  Petersburg, 
1900  (Russian),  quoted  by  Gundobin. 


PHYSIOLOGY  OF  DIGESTION 


15 


acids  and  glycerin.  All  these  ferments  are  probably  present  in 
the  pancreas  of  the  human  fetus  from  the  third  month  of  fetal  life 
onward.  At  birth  the  amount  of  trypsin  and  steapsin  is  less  than 
in  the  adult,  and  amylopsin  is  always  found  during  the  first  week 
of  life  and  increases  in  amount  with  the  age  of  the  infant.^-  ^'  ^'  ^ 
In  chronic  diseases  such  as  congenital  syphiUs  and  "  enterocoUtis " 
there  may  be  an  interstitial  pancreatitis  with  a  corresponding 

TABLE  5 


Age 

Number  of 

Wt.  in 

Average 

length  in 

cm. 

Width  in 

Thickness  in 

cases 

grammes 

cm. 

cm. 

3  mos.  fetus 

1 

0.07 

1.1 

0.4  -0.2 

4     «      " 

2 

0.115 

1.65 

0.75-0.27 

0.33-0.17 

5     "      " 

3 

0.38 

3.2 

0.8  -0.5 

0.34-0.21 

6     "      " 

6 

0.38 

3.2 

0.8  -0.48 

0.38-0.25 

7     "      " 

2 

0.76 

4.35 

1.0  -0.63 

0.4  -0.25 

8     "      " 

2 

1.18 

4.32 

1.2  -0.7 

0.6  -0.35 

9     "      " 

4 

1.63 

5.7 

1.5  -0.85 

0.58-0.35 

1-2  months 

3 

2.61 

6.93 

1.6  -0.9 

0.66-0.56 

2-3 

3 

2.64 

7.54 

1.6  -0.9 

0.65-0.5 

3-4 

3 

4.93 

7.46 

2.1  -1.5 

0.8  -0.57 

4r-5 

3 

5.4 

7.5 

2.25-1.5 

0.85-0.8 

5-6 

3 

5.28 

7.0 

1.75-1.25 

0.95-0.65 

&-9 

3 

7.37 

8.2 

2.0  -1.6 

1.0  -0.65 

9-12      " 

3 

8.67 

9.5 

2.0  -1.2 

0.9  -0.45 

weakening  of  the  pancreatic  ferments  (Gundobin).  Hess  ^  has 
shown  that  lipase  (steapsin)  may  be  deficient  in  acute  intestinal 
indigestion  while  the  two  other  pancreatic  ferments  are  present 
in  considerable  amounts. 

The  secretin  of  the  intestinal  mucous  membrane  stimulates  the 
production  of  the  pancreatic  ferments.  Bayliss  and  Starling* 
showed  that  when  inorganic  or  organic  acids  were  discharged  from 
the  stomach  into  the  duodenum  secretin  was  set  free.  When  se- 
cretin is  carried  by  the  blood  to  the  pancreas  it  starts  the  pan- 
creatic secretion.  Secretin  has  been  found  in  the  fetus  and  in 
many  new-bom  babies.    The  peptic  ferment,  trypsin,  is  present 

*  Hess:  Am.  Jour.  Dis.  Children,  1912,  ii,  205,  Summary  of  Literature. 
«  Moro:  Jahrb.  f.  Kinderh.,  1898,  xlvii,  342. 

'  Ibrahim  and  Gross:  Ref.  Deut.  med.  Wochenschr.  Vereinsbeilage,  1908, 
XXV,  1128. 

*  Hartge:  loc.  dt. 

»  Hess:  Am.  Jour,  Dis.  Children,  1913,  v,  268. 

«  Bayiiss  and  Starling:  Jour.  Physiol.,  1902,  xxviii,  325-53,  1903,  174, 


16  PHYSIOLOGY  OF  DIGESTION 

in  the  pancreas  as  the  pro-ferment  trypsinogen.  Many  fetuses 
have  trypsinogen,  but  no  trypsin.  The  secretion  of  enterokinase 
is  called  forth  by  the  pancreatic  juice  and  has  been  demonstrated 
in  new-bom  and  premature  babies  by  Ibrahim.  The  pancreatic 
ferments,  with  the  added  action  of  erepsin,  carry  the  digestion  of 
proteins  from  albumoses  and  peptones  into  amino  acids. 

The  fat-splitting  ferment,  called  hpase  or  steapsin,  is  active  in 
acid,  alkah,  or  neutral  surroundings.  This  ferment  is  present  in 
the  pancreatic  juice  in  part  as  a  pro-enzyme,  which  is  changed  by 
the  bile  into  steapsin.  The  bile  in  this  way  increases  the  fat- 
spUtting  power  of  the  pancreatic  ferments  ^  and  facihtates  emul- 
sion. 

There  is  no  work  upon  the  sugar-splitting  ferments  in  babies 
other  than  that  of  Ibrahim,  ^  Miura,*  neither  of  whom  are  able 
to  find  any  in  the  new-born. 

LIVER 

The  weight  of  the  liver  post-mortem  depends  upon  whether  or 
not  it  is  full  of  blood.  When  the  former  weight  is  taken,  it  is 
known  as  the  ''physiological  weight,"  and  the  latter  as  the  ''post- 
mortem weight."  The  physiological  weight  is  obtained  by  filling 
the  fiver  to  its  maximum  with  water,  after  it  has  been  removed 
from  the  body. 

The  following  table  of  Kowalski's^  gives  the  weights  of  the 
livers  of  fifty  normal  infants: 

1  Furth  and  Schutz:  Hofm.  Beit.  z.  chem.  Physiol,  u.  Path.,  1907,  ix,  28. 

2  Ibrahim:  Verhandl.  d.  Gesell.  fur  Kinderh.  Koln.,  1908,  21. 
'  Miura:  Zeitschr.  f.  Biologie.  32  Neue  Folge,  1895,  xiv,  266. 
*Kowalski:  Die  Leber  des  Kindes.  Diss.  St.  Petersburg,  1900  (Russian), 

quoted  by  Gundobin. 


PHYSIOLOGY  OF  DIGESTION 


17 


TABLE  6 

Total  wt.  of  liver 

Body  weight  in 

Age 

No.  of  cases 

in  gram 

gram 

5    mos.  fetus 

1 

39 

650 

'7                  11             U 

1 

70 

1,320 

SH   "     " 

1 

110 

2,000 

9        "      "     female 

1 

100 

1,900 

9        "      "     male 

2 

92 

2,000 

New-bom 

3 

130 

3,000 

1-7  days 

4 

133.5 

3,150 

2-3  mos. 

6 

187.5 

4,075 

3-4     " 

4 

259 

4,350 

4-5     " 

2 

248 

5,900 

8-10  " 

2 

320 

7,000 

15      " 

2 

325 

10,000 

The  weight  of  the  hver  in  comparison  with  that  of  the  body  is 
4.33%  in  the  new-born  and  2.85%  in  the  adult.  The  function  of 
the  hver  is  to  manufacture  bile  and  to  change  carbohydrates, 
proteins  and  fats  into  glycogen.^  Its  cells  also  play  an  important 
part  in  the  formation  of  urea. 

Bile. — The  composition  of  bile,  according  to  Geptner,^  is  as 
follows : 

TABLE  7 


Age 

Ammmi 

Composition  of  the  bile 

Water 

Solids 

Mucin 

Bile 

salts 

Sodium 
glyco- 
cholic 
acid 

Sodium 
tauro- 
cholic 
acid 

Choles- 
terin. 

Fat.  Le- 
cithin 

Mineral 
salts 

Per  cent 

93.54 

6.46 

1.56 

2.35 

1.40 

0.90 

1.86 

0.53 

Infants 

of  100  parts 
of  dry  sub- 
stance 

100 

25.23 

35.09 

21.22 

13.11 

28.44 

8.08 

Per  cent 

91.87 

8.13 

1.54 

3.32 

2.21 

1.06 

2.26 

0.86 

12-18 
months 

of  100  parts 
of  dry  sub- 
stance 

100 

19.13 

40.88 

27.11 

13.16 

27.18 

10.89 

Per  cent 

87.61 

12.37 

1.98 

6.38 

3.49 

1.57 

1.99 

0.82 

Adults 

of  100  parts 
of  dry  sub- 
stance 

100 

16.0 

51.57 

28.21 

12.69 

16.09 

6.62 

'  Kowalski:  loc.  cit. 

^  Geptner:  Die  Chemische  Zusammensetzung  der  Galle  des  Kindes.  Diss. 
St.  Petersburg,  1900  (Russian),  quoted  by  Gundobin. 


18 


PHYSIOLOGY  OF  DIGESTION 


The  bile  salts  are  of  importance  in  activating  the  pancreatic 
juices  and  in  acting  with  them  in  sphtting  the  fat.  The  hver,  be- 
sides secreting  the  bile,  acts  as  a  protection  against  bacterial  and 
other  poisons.^ 


INTESTINES 

The  length  of  the  intestinal  tract  increases  fairly  regularly  with 
the  age  of  the  infant. 

The  table  on  this  page  is  the  result  of  measurements  by  Debele:  ^ 
Small  Intestine. — The  juices  of  the  small  intestine  contain  in- 
vertin  (Ibrahim),  both  in  the  fetus  and  in  the  new-bom.  Several 
writers,^'  ■*•  ^  have  demonstrated  erepsin  in  the  fetus  and  other 
ferments  have  been  identified  by  other  writers.  Lang  and  Fenger,^ 
studied  the  reaction  of  the  small  intestine  in  animals  and  man, 
employing  an  electrometric  method.  An  alkaline  reaction  is  less 
coDomon  than  an  acid  one,  even  close  to  the  duodenum,  where  a 

TABLE  8 


Length  of  trunk 

from  the  7th 

Length  of  the 

Length  of  the 

Age 

Number  of 

cervical  vertebra 

small  intestine 

large  intestine 

cases 

to  the  coccyx 

in  cm. 

in  cm. 

in  cm. 

1  month 

4 

21.5 

296.4 

63.3 

1-2  mos. 

6 

21.1 

319.1 

65.1 

2-3     " 

14 

22.2 

358.1 

70.6 

3^     " 

5 

23.1 

379.4 

71.2 

4-5     " 

4 

25.5 

383.4 

72.3 

5-6     " 

5 

25.1 

380.3 

69.2 

7-9     " 

2 

27.0 

412.4 

80.5 

6-12  " 

6 

27.0 

419.8 

83.9 

Average 

46 

23.5 

365.3 

71.6 

temporary  alkaUnity  may  be  established  by  bile.    The  usual  reac- 
tion is  between  1  to  3  X  10"^. 

» Uffenheimer:  Ergebnisse  d.  inn.  Med.  et  Kinderh.,  1908,  No.  2,  271. 

*  Debele:  Die  Lange  des  Darmkanals  im  Kindesalter.  Diss.  St.  Petersburg, 
1900  (Russian),  quoted  by  Gundobin. 

»  Langstein  and  Soldinr  Jahrb.  f.  Kinderh.,  1908,  Neue  Folge,  Ixvii,  9. 

*  Jaeggy:  Zentralblatt  f.  Gynak.,  1907,  No.  35,  1060. 
6Foa:  Miinch.  med.  Wochenschr.,  1907,  2201. 

*  Science,  1917,  xlvi,  p.  000. 


PHYSIOLOGY  OF  DIGESTION  19 

Carbohydrates  are  split  into  monosaccharides  in  the  small  intes- 
tines, where  they  are  absorbed.  The  specific  ferments,  invertin, 
lactase,  and  maltase,  convert  the  corresponding  sugars  into  mono- 
saccharides and  are  either  present  in  the  digestive  juices  or  in  the 
mucous  membrane.  Food  stays  a  relatively  short  time  in  the 
small  intestine,  but  during  that  time  is  mixed  with  and  acted  upon 
by  the  digestive  juices  so  that  it  is  ready  for  absorption  before  it 
reaches  the  large  intestine. 

There  is  nothing  definitely  known  about  the  secretions  of  the 
large  intestine. 

Digestion-Leucocytosis. — The  evidence  on  this  point  is  con- 
flicting. Recent  work  shows  that  it  is  only  present  in  12%  of  the 
cases,  while  in  the  remainder  there  is  no  increase  in  the  leucocytes 
after  the  ingestion  of  food  but  rather  a  decrease.  The  probable 
explanation  being  that  they  are  drawn  away  from  the  peripheral 
circulation  to  the  digestive  tract. 


CHAPTER  II 
THE  DIGESTION  AND  METABOLISM  OF  FAT  ^ 

The  fat  in  the  infant's  food  is  principally  in  the  form  of  neutral 
fat.  SaUva  has  no  action  upon  it,  and,  although  saponification 
begins  in  the  stomach,  it  probably  is  not  carried  on  to  a  point 
which  influences  to  any  degree  the  future  digestion  of  the  fat.  The 
action  of  the  fat-spUtting  ferment  of  the  stomach  is  eventually 
stopped  entirely  by  the  acid  reaction  of  the  stomach  contents.  The 
action  of  the  gastric  secretions  is  of  importance  indirectly,  because 
when  milk  is  coagulated  by  rennin,  most  of  the  fat  is  ensnared  in 
the  meshes  of  the  casein  curds,  and  the  casein  coating  must  be 
first  digested  before  the  digestive  juices  can  reach  the  fat.  There 
is,  therefore,  very  Httle  opportunity  for  the  absorption  of  fat  in  the 
stomach.  This  ensnaring  of  the  fat  by  the  casein  may  be  of  phys- 
iological importance  in  preventing  the  liberation  of  too  large  an 
amount  of  fat  in  the  intestinal  canal  at  one  time. 

Fat  has  a  definite  influence  on  the  emptying  time  of  the  stomach, 
large  amounts  tending  to  delay  it.^  Large  amounts  of  fat  in  the 
food  are,  according  to  Tobler^  of  etiological  significance  in  the 
pathogenesis  of  pyloric  spasm.  He  found  in  the  stomach  of  one 
infant  more  fat  than  had  been  given  to  it  during  the  previous 
twenty-four  hours.  He  also  calculated  that  one  Hter  of  milk  would 
cause  one  and  a  half  Uters  of  digestive  juices  to  be  secreted. 

The  real  digestion  of  fat  commences  when  it  reaches  the  small 
intestines,  where  it  undergoes  a  physical  change.  The  fat  is 
first  of  all  subdivided  by  the  alkahne  salts  of  the  bile,  and  of  the 
pancreatic  and  intestinal  juices.  Fatty  acids,  which  are  formed 
as  the  result  of  the  action  of  the  fat-splitting  ferments,  react  with 
the  alkaline  carbonates  present  to  form  soaps.  The  soaps  which 
result  make  the  fat  particles  still  smaller  and  form  an  emulsion. 

Absorption. — There  is  considerable  evidence  to  show  that  neu- 
tral fat  (unspht  fat),  is  not  absorbed  as  such  into  the  intestinal 

^  Tobler  and  Bessau:  AUegemeine  Fathologische  Physiologie  der  Ernahrung 
und  des  Stoffwechsels  im  Kindesalter,  Wiesbaden,  1914,  has  been  consulted 
and  quoted  freely  in  this  section. 

*  Tobler  and  Bogen:  Monatsschr.  f.  Kinderh.,  vii,  12. 

» Tobler:  Verhandl.  d.  Gesellschaft  f.  Kinderh.,  1907,  411. 

20 


DIGESTION  OF  FAT 


21 


wall:  for  example,  hydrous  wool  fat  and  paraffin,  which  may  be 
made  into  emulsions  but  cannot  be  split,  are  not  absorbed. "^  It 
has  also  been  shown  by  animal  experimentation  that  the  amount 
of  fat  in  the  chyme  is  directly  proportional  to  the  amount  of  fat 
which  has  been  spUt.^  It  is  also  taught  by  some  that  fat  is  ab- 
sorbed both  in  the  form  of  an  emulsion  and  in  the  form  of  water- 
soluble  soaps,  neither  view  excluding  the  other.  Langworthy  and 
Hobnes,^  studied  the  digestibility  of  fat  in  the  adult  and  found 
that  its  "coefficient  of  digestibility"  was  dependent  on  its  melt- 
ing point;  the  lower  the  melting  point  the  greater  the  digesti- 
bihty.    This  is  shown  in  the  following  table: 


Fat  studied 

Coefficient  of 
digestibility 

% 

Melting  point 
degrees  C. 

Butter  fat 
Lard 
Beef  fat 
Mutton  fat 

97 
97 
93 

88 

32 
35 
45 
50 

Bloor  *  found  that  substances  similar  to  food  fat  in  that  they 
emulsified  well,  were  soluble  in  fat  solvents  and  were  Uquid  at 
temperatures  below  that  of  the  body,  but  could  not  be  converted 
into  a  water  soluble  form,  and  were  not  absorbed  at  all  in  the  intes- 
tinal canal.  He  concluded  that  the  slow  passage  of  fats  from  the 
stomach,  the  abundant  provisions  for  hydrolysis  and  for  the  ab- 
sorption of  fat-like  substances  which  can  be  changed  to  a  water 
soluble  form,  make  it  extremely  probable  that  saponification  is  a 
necessary  preliminary  to  absorption.  The  significance  of  the  mech- 
anism involved  is  Uttle  understood,  but  one  of  its  uses  would 
appear  to  be  to  exclude  undesirable  fat-like  substances  which 
would  otherwise  be  carried  into  the  body  with  the  fats. 

Kastle  and  Loevenhart  ^  demonstrated  the  almost  universal  pres- 
ence of  hpase  in  the  tissues,  and  showed  that  this  ferment  could 
reverse  its  action.  That  is  to  say,  it  can  synthetize  or  change 
soaps  back  into  neutral  fats  as  well  as  split  neutral  fats  and  form 
soaps.    It  is,  therefore,  possible  that  the  soaps,  which  have  been 

» Connstein,  W.:  Arch.  f.  Anat.  u.  Ph3rsioI.,  1899,  30;  Henriques  and  Han- 
sen: Zentralblt.  f.  Physiol.,  1900,  xiv,  313. 

»  Levites:  Ztschr.  f.  physiol.  Chem.,  xUx,  273;  liii,  349. 

» Bull.  136,  Expt.  Sta.  U.  S.  Dep't  Agric.,  1903,  p.  113. 

*  Bloor:  Jour.  Biol.  Chem.,  xv,  105,  and  Jour.  Biol.  Chem.,  1914,  xvi,  517. 

•Kastle  and  Loevenhart:  Am.  Chem.  Jour.,  1900,  xxiv,  491. 


22  DIGESTION  OF  FAT 

formed  during  the  digestion,  are  changed  during  their  passage 
through  the  intestinal  epithelium  by  the  reversible  action  of  lipase 
into  neutral  fat,  because  neutral  fat  is  found  almost  exclusively 
in  the  lymph  stream.  Whitehead's  ^  experiments  on  cats  seem  to 
strengthen  this  statement  because,  he  found  that  butter-fat  stained 
with  Sudan  III  lost  the  stain  during  absorption  (soaps  will  not 
stain  with  Sudan  III) ;  Sudan-staining  fat  was  seen  in  the  lumen 
of  the  intestine;  none  was  seen  in  the  intestinal  epithelium  and  a 
Sudan-staining  fat  was  again  found  in  the  lacteals  of  the  villi. 
The  weight  of  evidence,  therefore,  is  that  fat  must  be  converted 
into  a  water  soluble  form,  soap,  before  it  can  be  absorbed.  The 
fate  of  glycerin,  the  other  end  product  of  fat-spUtting  is  un- 
known. 

Noll 2  and  Wilson'  conclude  from  their  studies  with  animals 
that  the  epithelium  of  the  intestinal  mucous  membrane  plays  a 
part  in  the  absorption  of  fat.  The  emulsified  fat  is  taken  up  into 
the  striated  cells  bordering  the  villi.  These  cells  contain  a  con- 
siderable amount  of  fat  before  the  fat  can  be  detected  in  the  lac- 
teals. A  stage  is  then  reached  in  which  the  fat  content  of  the  mu- 
cosa further  increases  and  at  the  same  time  removal  through  the 
lacteals  sets  in.  The  fat  is  then  found  in  the  lacteals  until  all  the 
fat  has  been  removed  from  the  epithelial  cells.  There  is  hardly  any 
evidence  to  show  that  the  fat  can  be  carried  from  the  epithelial 
cells  to  the  lacteals  by  leucocytes.  Samelson  ^  has  foimd  a  fat- 
spUtting  enzyme  in  the  blood  of  infants. 

About  two-thirds  of  the  fat  in  the  food  enters  the  thoracic  duct 
as  chyle  and  may  be  accounted  for  in  this  way.  The  fate  of  the 
other  third  is  not  clear.  It  may  find  its  way  to  the  liver  by  way  of 
the  intestinal  capillaries.  The  subsequent  course  and  fate  of  fat 
was  unknown  until  Bloor  ^  added  new  light  to  the  subject.  He 
found  that  lecithin  in  the  blood  increased  during  the  absorption 
of  fats.  This  increase  was  mostly  in  the  blood  corpuscles  and 
very  little  in  the  plasma.  The  fatty  acids  increased  in  both 
plasma  and  corpuscles,  but  to  a  greater  extent  in  the  latter; 
while  cholesterol  showed  no  change  during  digestion.  Bloor  con- 
cludes that  the  close  connection  between  the  fatty  acids  and 
lecithin  can  be  interpreted  to  mean  that  all  absorbed  fat  passes 
through  the  lecithin  stage. 

1  Whitehead:  Am.  Jour.  Physiol.,  1909,  xav,  294. 

*  Noll:  Arch.  ges.  Physiol.,  cxxxvi,  208. 

'Wilson:  Trans.  Canadian  Inst.  Sept.,  1906,  viii,  241. 

*  Samelson:  Zeitschr.  f.  Kinderh.,  1912,  iv,  205. 
"  Jour.  Biol.  Chem.,  1916,  xxiv,  447. 


DIGESTION  OF  FAT  23 

When  the  fat  has  entered  the  blood  stream  it  can  be  demon- 
strated by  the  ultra  microscope.  When  fat  is  present  in  the  blood 
after  food  has  been  taken,  the  condition  is  called  digestion  lipemia. 
It  commences  two  to  three  hours  after  meals  and  disappears  after 
seven  to  eight  hours. ^  The  height  of  the  curve  is  dependent  on  the 
amount  of  fat  in  the  food,  and  also  on  the  age  and  condition  of  the 
infant. 

The  absorption  of  fat  is  extraordinarily  good  in  health  in  babies 
fed  on  cow's  milk  as  well  as  in  those  fed  on  human  milk.  It  is 
usually  over  90%  and  may  be  as  high  as  98%  of  the  fat  ingested;  ^ 
8%  to  11%  of  the  ingested  fat  is  absorbed  in  the  upper  part 
of  the  small  intestine  ^  and  the  absorption  of  fat  is  nearly  com- 
plete at  the  ileocecal  valve.^  The  large  intestine  is  capable  of  ab- 
sorbing fat  in  large  amounts  under  special  favorable  conditions,* 
but  under  ordinary  circumstances  absorption  here  is  probably 
very  sHght. 

The  results  of  estimations  of  the  amount  of  fat  in  the  stools 
of  babies  in  starvation  and  in  health  make  it  probable  that  the 
greater  part  of  the  fecal  fat  comes  from  the  food  and  not  from  the 
intestinal  secretions.^  It  is  evident,  therefore,  that  the  study  of 
the  fat  in  the  stools  with  the  microscope  will  give  valuable  infor- 
mation about  the  digestion.  It  is  necessary  first  to  know  how  much 
fat  may  normally  be  found  in  a  stool.  There  is  a  comparatively 
large  amount  of  fat  present  in  the  first  days  of  life,  and  this  amount 
gradually  becomes  less  as  the  babies  grow  older,^  decreasing  from 
50%  of  the  dried  stools  to  between  14  and  25%.  There  is  so 
much  fat  passed  in  the  stools  during  the  early  weeks  that  it  is 
practically  impossible  to  ascertain  by  simple  microscopic  ex- 
amination whether  there  is  an  excess  or  not.  In  later  infancy 
less  fat  is  present  and,  therefore,  microscopic  examinations  are 
of  more  value.  In  normal  and  in  many  pathologic  conditions  the 
greater  part  of  the  fat,  75%  or  more,  is  in  the  form  of  fatty  acids 
and  soaps. 

1  Neumann:  Wien,  klin.  Wochenschr.,  1907,  851;  Schelble:  Munchen  med. 
Wochenschr.,  1908,  No.  10,  p.  492;  Bahrdt:  Breslauer  Tagung  der  Freien  Ver- 
einigung  fiir  wissenschaftliche  Padiatrie,  1908;  Monatschr.  f.  Kinderh.,  vii, 
106. 

*  Czemy  and  Keller:  "Des  Kindes  Emahrung,  EmahrungstSrungen  und 
Emahrungstherapie,"  Leipzig  u.  Wien,  1906,  I,  263;  Freund:  Ergebn.  d.  inn. 
Med.  u.  Kinderh.,  1909,  iii,  139. 

'  Levites:  loc.  cU. 

*  Hamburger,  H.  J. :  Engelmann's  Arch.,  1900,  433. 

*  Czerny  and  Keller:  loc.  cU. 

« Talbot,  F.  B.:  Boston  Med.  and  Surg.  Jour.,  1909,  vol.  clx.  No.  1,  13. 


24  METABOLISM  OF  FAT 


METABOLISM 

Methods. — Most  of  the  earlier  figures  of  the  metabolism  of  fat 
were  obtained  by  the  Rosenfeld  extraction  method,^  or  one  of  its 
modifications.  Later  Kumagawa  and  Suto  ^  criticised  these  meth- 
ods and  devised  a  saponification  method  which  goes  under  their 
name.  These  two  methods  are  the  ones  most  commonly  used  on 
the  continent.  The  Folin-Wentworth  method  ^  (extraction)  is 
now  used  in  America  almost  to  the  exclusion  of  the  other  two 
methods.  Gephart  and  Csonka  ^  have  recently  shown  the  pres- 
ence of  errors  in  all  of  the  above  methods  and  have  described  a 
method  by  which  they  have  endeavored  to  overcome  these  errors.^ 
Up  to  date  there  are  no  metabolism  figures  in  infancy  which  were 
obtained  by  this  method.  When  the  methods  are  studied,  it  be- 
comes obvious  that  figures  obtained  by  one  method  cannot  fairly 
be  compared  with  those  obtained  by  another  method,  because  they 
probably  do  not  represent  the  same  things.  It  is  obvious  also 
that  slight  differences  in  figures  are  of  no  significance  and  that  only 
the  most  striking  differences  are  of  practical  importance.  Un- 
fortunately, the  clinical  status  of  the  infant  is  not  sufficiently  con- 
trolled and  recorded  in  most  instances  and  the  possibilities  of 
error,  both  from  errors  in  chemical  technique,  and  in  clinical  ob- 
servation, are  numerous.  Despite  these  facts,  it  seems  wise  to 
summarize  what  we  think  we  know  about  the  digestion  and  ab- 
sorption of  fat  in  health  and  disease. 

Fat  Excretion  on  Fat-free  Food. — A  careful  analysis  of  the 
figures  that  are  at  present  available  shows  that  even  when  the 
quantity  of  fat  in  the  food  is  very  minute,  an  ether  soluble  sub- 
stance, which  is  recorded  by  investigators  as  fat,  is  found  in  the 
stools.  In  ^ost  instances  in  infants  the  amount  of  this  substance 
is  smaller  than  the  amount  of  fat  in  the  food,  and  if  it  is  fat  it 
might  very  well  originate  in  the  food.^  On  the  other  hand,  since 
fasting  adults  have  had  small  quantities  of  fat  in  the  stools,  it  is 
argued  that  this  fat  must  come  from  the  body.    The  amount  of 

» Rosenfeld:  Centralb.  f.  inn.  Med.,  1900,  xxi,  833. 

^  Kumagawa  and  Suto:  Biochem.  Zeitschr.,  1908,  viii,  212. 

3  Folin  and  Wentworth:  Jour.  Biol.  Chem.,  June,  1909-10,  vii,  421. 

*  Gephart  and  Csonka:  Jour.  Biol'.  Chem.,  Dec,  1914. 

*  A  Rapid  Nephelometric  Method  for  the  Determination  of  Fat  in  the 
Stools  has  been  recently  described  by  Laws  and  Bloor:  Am.  Joiu*.  Dis.  Chil- 
dren, 1916,  xi,  229. 

*  See  expts.  of  Aschenheim  (Kumagawa  and  Suto  method),  Jahrb.  f.  Kin- 
derh.,  1913,  Ixxvii,  505. 


METABOLISM  OF  FAT  25 

fat  in  question  is  so  small  that  the  discussion  is  of  more  theoretical 
than  practical  importance. 

Fat  Absorption  in  Health. — It  is  generally  agreed  that  the  fat 
absorption  of  healthy  infants  is  very  high  both  in  the  breast-fed 
and  in  the  artificially  fed.  Uffelmann  ^  found  that  a  breast-fed 
infant  absorbed  approximately  97.8%  of  the  fat  ingested.  Shaw 
and  Gilday  ^  found  the  absorption  96%,  while  Nob^court  and 
Merklen^  found  the  absorption  of  fat  respectively  98.3,  99.7, 
98.27,  98.23,  and  98.62%  in  five  healthy  breast-fed  infants.  Fur- 
ther figures  are  given  by  Czerny  and  Kellar.^ 

The  absorption  of  fat  in  normal  artificially-fed  babies  is  also 
extraordinarily  good  and,  according  to  Freund,  it  may  remain  ab- 
solutely normal  even  under  abnormal  conditions  of  nutrition.  He 
records  instances  with  "soap  stools"  in  which  the  fat  absorption 
reached  as  high  as  97%  of  the  intake  (see  Czerny  and  Kellar,^  and 
Freund)  .6  Freund  gives  91.86%  to  98.98%  as  the  figures  for  the 
absorption  of  fat  for  healthy,  breast-fed  infants.  The  figures  are 
somewhat  lower  in  the  babies  he  calls  "apparently  normal,"  but 
analyses  of  these  figures  show  that  these  babies  are  considerably 
under  the  average  weight  for  their  age  and  can,  therefore,  not 
be  considered  "average  normal."  Nevertheless  many  of  these 
infants  show  a  very  good  absorption  of  fat. 

The  significance  of  fatty  acids  and  soaps  is  as  yet  unknown. 
Freund^  has  shown  that  an  acid  dyspeptic  stool  can  be  changed 
in  many  instances  to  a  formed  "soap  stool"  by  a  relative  increase 
in  the  amount  of  casein,  while  an  alkaline  soap  stool  can  be  changed 
into  an  acid  stool  by  a  relative  increase  in  the  amount  of  carbohy- 
drates. Coincident  with  the  change  from  an  acid  to  an  alkaline 
stool  there  is  a  change  of  the  intestinal  flora.  Bahrdt^  in  contradis- 
tinction to  Freund  (see  p.  22)  has  recently  shown  that  babies  passing 
"soap  stools"  may  have  diminished  powers  of  absorption  and  that 
they  may  lose  more  than  was  formerly  taught.  He  found  the 
absorption  of  fat  (Kumagawa  and  Suto  method)  as  follows: 

1  Uffelmann:  quoted  by  Tobler  and  Bessau,  loc.  cU. 

*  Shaw  and  Gilday:  Brit.  Med.  Jour.,  1906,  ii,  932. 

'  Nob^court  and  Merklen:  Rev.  mens  d.  Mai.  de  I'enfance,  1904,  xxii,  337. 

*  Czerny  and  Kellar:  loc.  cU. 

6  Freund:  Ergeb.  d.  inn.  Med.  u.  Kinderh.,  1909,  iii,  15&-159. 
•Freund:  loc.  cit. 

">  Bahrdt,  H.:  Jahrb.  f.  Kinderh.,  1910,  bad,  249;  Holt,  Courtney  &  Fales: 
Am.  Jour.  Dis.  Children,  1915,  ix,  533. 


26 


METABOLISM  OF  FAT 


TABLE  9 


Name  of  baby 

Age, 
months 

Body 

Weight, 

gm. 

Fat  ab- 
sorbed, 
per  cent 

Character  of 
stools 

Schroder,  7  days 

Schxiler,  7  days 

Weiss  la,  5  days 

Weiss,  lb 

9 
2 

9/io 

g/ix) 

10 

7470 
3945 
3750 
3750 

3900 

82.4 
83.2 
81.9 
86.0 

93.0 

"Soap  stools" 
Mostly  "soap  stools" 
"Soap  stools" 
"Soap  stools" 

Normal  stools 

Weiss  II,  8  days 
(Breast  and  skim  milk) 

The  fat  absorption  in  these  babies  with  ''soap  stools"  is,  there- 
fore, considerably  less  than  that  of  normal  infants.  There  is,  how- 
ever, not  such  a  loss  of  fat  as  in  diarrhea.  The  formation  of  "soap 
stools"  may  be  prevented  by  the  addition  of  whey  to  the  diet.^ 

It  is  very  difficult  to  determine  in  the  cases  that  have  not  been 
previously  investigated  how  much  their  powers  of  digestion  had 
been  injured  by  previous  poor  feeding  or  disease.  Conclusions 
as  to  the  effect  of  the  food  on  sick  babies,  on  this  account,  must  be 
very  conservative.  There  seems  to  be  little  doubt,  however,  that 
increased  peristalsis  results  in  an  increased  loss  of  fat  in  the  stools. 
Certain  phases  of  this  question  will  be  considered  in  more  detail 
later.  Increased  loss  of  fat  in  the  stools  may  occur  in  any  diarrhea, 
whether  it  be  due  for  example,  to  an  acute  infection,  or  to  chilling, 
or  to  an  excess  of  sugar  in  the  food.  Birk's  observations  on  Groe- 
ger  III,  during  a  period  in  which  the  temperature  was  elevated 
and  there  were  frequent  thin  stools,  showed  an  absorption  of  only 
79%.  Courtney^  says  that  the  lowest  absorption  in  her  cases, 
Janes  52.3%  and  Stoker  34.2%,  was  the  result  of  increased  peristal- 
sis and  diarrhea.  Usuki  ^  found  that  when  large  amoimts  of  malt 
extract  were  added  to  the  food  of  an  infant  with  alkaline  stools 
the  loss  of  fat  in  the  stools  increased  from  10%  to  15%.  The 
same  results  were  recorded  for  lactose  by  Talbot  and  Hill,^  who 
found  in  their  case  that  the  absorption  of  fat  while  the  digestion 
was  good  was  90%  and  that  during  a  "sugar  diarrhea"  it  dropped 
to  75%. 

The  percentage  of  fat  in  the  dried  stool  is  higher  in  parenteral 
febrile  infections  than  in  health.    Uffelmann  ^  found,  for  example, 

'  Giffhom:  Jahrb.  f.  Kinderh.,  1913,  Ixxviii,  531. 
'Courtney:  Am.  Jour.  Dis.  Children,  1911,  i,  321. 
'Usuki:  Jahrb.  f.  Kinderh.,  1910,  Ixxii,  18. 
♦Talbot  and  Hill:  Am.  Jour.  Dis.  Children,  1914,  viii,  218. 
6  Uffelmann:  quoted  by  Tobler  and  Bessau,  loc.  cit. 


METABOLISM  OF  FAT  27 

that  in  an  eight  months'  old  infant  with  acute  bronchitis  and  fever 
the  fat  excretion  in  the  stools  was  as  follows : 

TABLE  10 

Fat 

4th  day 40.7%  of  dried  stool 

7th  day 37.8%  of  dried  stool 

9th  day 25.0%  of  dried  stool 

13th  day 15.2%  of  dried  stool 

Fat  Diarrhea. — ^Demme  ^  and  Biedert  ^  described  a  condition 
which  they  called  a  fat  diarrhea  which  was  characterized  by 
frequent,  acid,  diarrheal  stools.  Tobler  thinks  that,  on  account 
of  their  acidity,  these  stools  are  not  characteristic  of  a  primary 
fat  indigestion,  but  that  they  may  be  secondary  to  some  other 
form  of  indigestion  which  causes  rapid  peristalsis.  He  cites,  as  evi- 
dence in  favor  of  this  point  of  view,  the  fact  that  such  a  diarrhea 
will  stop  when  the  food  is  changed  to  "Eiweissmilch,"  even  though 
the  percentage  of  fat  remains  the  same.  It  is  a  fact,  nevertheless, 
that  in  certain  instances,  in  which  very  large  amounts  of  fat  have 
been  fed  to  young  infants,  they  have  passed  three  or  four  stools 
daily  of  the  yellow  color  of  Indian  meal  and  the  consistency  of 
mush.  Careful  inspection  of  such  stools  shows  drops  of  oil  on  the 
surface  of  and  intermixed  with  the  stool,  while  the  microscope 
shows  that  the  stool  is  composed  almost  entirely  of  fat.  When 
the  mnount  of  fat  is  reduced  in  these  cases  without  any  other 
change  in  the  food,  the  digestion  becomes  normal.  Such  cases 
are  true  fat  diarrheas. 

Whether  the  fat  in  the  stool  is  in  the  form  of  fatty  acids  or  soaps 
depends  chiefly  upon  the  reaction  of  the  stool,  which  in  its  turn 
depends  upon  the  relation  of  the  food  components  to  each  other. 
Talbot^  has  shown  that  "soft  curds"  or  fatty  curds,  when  al- 
kaline to  litmus  paper,  are  composed  principally  of  soaps  and, 
when  acid  to  htmus  paper,  principally  of  fatty  acids. 

The  presence  of  a  large  amount  of  soaps  presumably  affects  the 
absorption  of  the  various  salts.  The  technical  difficulties  in  deter- 
mining the  amount  of  calcium  and  other  salts  in  the  stools,  make 
nearly  all  the  figures  very  unrehable.*  The  usual  conclusions 
from  metaboUsm  experiments  are  that  in  the  normal  infant,  with 

^  Demme:  Jahrb.  iiber  die  Thatigkeit  des  Jennerschen  Kinderspitals  in 
Berlin,  1874  and  1877;  quoted  by  Hecht,  Die  Faeces  des  Sauglings,  etc.,  p.  128. 

*  Biedert:  Jahrb.  f.  Kinderh.,  1879,  xiv,  336;  ibid.,  1888,  xxviii,  21. 
» Talbot:  Boston  Med.  and  Surg.  Jour.,  1909,  clx,  13. 

*  According  to  Prof.  Folin  only  those  figures  of  the  calcium  metabolism 
obtained  by  McCrudden's  methods  are  of  any  value. 


28  METABOLISM  OF  FAT 

a  normal  fat  absorption,  a  high  fat  intake  does  not  change  the 
mineral  composition  of  the  stools,  while  in  chronic  malnutrition 
the  output  of  salts  in  the  feces  is  considerably  raised  by  increasing 
the  fat  in  the  diet.^ 

Olive  oil  is  considered  by  some  authors  to  have  a  beneficial  ac- 
tion on  the  absorption  of  fat.  The  metaboUsm  experiments  of 
Courtney  ^  and  Freund  ^  apparently  bear  out  this  belief. 

Infantile  Atrophy. — "Alimentary  decomposition"  of  Finkel- 
stein — ("Marasmus").  When  the  literature  of  the  metabolism  of 
"infantile  atrophy"  is  studied  the  first  questions  which  arise  in 
the  student's  mind  are  what  is  the  clinical  picture  of  "infantile 
atrophy,"  and  are  all  the  cases  reported  under  that  name  suffering 
from  the  same  disease.  The  smnmaries  of  the  clinical  histories 
are  so  meager  that  it  is  impossible  to  draw  any  definite  conclusions 
from  them  and  the  statement  of  the  investigator  as  to  the  clinical 
status  of  the  given  infant  has  to  be  accepted.  This  state  of  affairs 
is,  of  course,  unfortunate,  but  with  the  present  disagreement 
among  authorities  as  to  what  the  disease  really  is,  it  cannot  be 
remedied.  With  modem  improvements  in  the  methods  of  di- 
agnosis it  is  possible  to  separate  out  chronic  tuberculosis  and 
hereditary  syphilis  as  definite  clinical  entities.  Prematurity  should 
also  be  set  aside  by  itself.  This  leaves,  to  be  classed  as  "infantile 
atrophy,"  those  cases  which  correspond  to  Holt's  ^  definition,  that 
"infantile  atrophy  is  the  extreme  form  of  malnutrition  seen  in 
infancy,  occurring  so  far  as  is  known,  without  constitutional 
or  local  organic  disease.  It  is  a  vice  of  nutrition  only."  There 
must  be  many  stages  of  the  disease  if  there  is  such  a  clinical  entity. 
These  facts  must  be  borne  in  mind  in  considering  the  subse- 
quent remarks. 

The  fat  content  of  the  body  of  an  atrophic  infant  as  compared 
with  the  normal  is  very  much  diminished.  Ohlmiiller  ^  found  that 
the  body  of  an  atrophic  infant  contained  only  3%  fat  as  com- 
pared to  21%  in  a  normal  infant.  Steinitz^  analyzed  the  bodies 
of  three  atrophic  infants,  weighing  3190,  2625  and  1960  grams,  and 
found  that  the  total  amount  of  fat  was  respectively  63.6,  37.9  and 
35.9  grams,  or  from  1.45  to  1.99%  of  the  total  mass,  as  compared 
with  from  12.3%  to  13.1%  in  the  normal. 

1  Freund:  Ergeb.  d.  inn.  Med.  u.  Kinderh.,  1909,  iii,  139. 

'Courtney:  Am,  Jour.  Dis.  Children,  1911,  i,  321. 

'Freund:  Biochem.  Zeitschr.,  1909,  xvi,  453. 

<Holt:  Dis.  of  Infancy  and  Childhood,  N.  Y.  and  London,  1911,  p.  227. 

"Ohlmiiller:  Zeitschr.  f.  Biol.  1882,  xviii,  78. 

•Steinitz:  Jahrb.  f.  Kinderh.,  1904,  lix,  447. 


METABOLISM  OF  FAT  29 

A  fatty  liver  is  occasionally  found  at  post-mortem  examination, 
but,  according  to  Holt, — "This  lesion  is  not  more  frequent  in  this 
condition  than  in  infants  dying  of  other  diseases."  Hayaslei  ^ 
recently  showed  that  in  five  out  of  eight  cases  of  "infantile  at- 
rophy" the  liver  contained  neither  fat  nor  lipoid  substances.  In 
two  cases  the  livers  were  fatty. 

According  to  many  authors^  the  digestive  ferments  are  more 
or  less  diminished  and  weakened  in  infantile  atrophy.  This  is 
especially  true  of  the  fat-splitting  ferment.  Hecht  believes  that 
there  is  a  connection  between  the  severity  of  the  disturbance 
and  the  diminution  in  the  amount  of  steapsin.  Wentworth* 
found  that  secretin  was  either  diminished  or  absent  in  these 
cases. 

The  metabohsm  of  fat  varies.  Freund  *  found  that  two  atrophic 
infants  with  "milchnahrschaden"  (soft  curds)  absorbed  respec- 
tively 90%  and  97%  of  the  fat,  except  in  one  instance  when  one 
absorbed  only  81.8%.  Bahrdt,^  on  the  other  hand,  found  an 
absorption  of  only  81.9,  82.4,  83.2,  86.0  and  93%. 

L.  F.  Meyer ^  studied  "infantile  atrophy"  in  different  stages 
and  with  different  foods.  He  found  in  baby  Kajitzki  in  periods 
I  and  II,  in  which  whole  milk,  diluted  one-half,  was  given,  that 
the  absorption  of  fat  was  respectively  74.2%  and  24.9%.  In  the 
first  period  there  was  a  slight  gain  in  weight,  and  in  the  second 
period  a  marked  loss  in  weight,  with  a  corresponding  loss  of  fat 
in  the  stool.  In  periods  III,  IV,  and  V,  the  absorption  of  fat  was 
respectively  51.0,  68.3,  and  78.6%,  and  during  the  last  period 
there  was  a  gain  in  weight.  Baby  Bentler  did  not  show  the  same 
loss  of  fat,  but  there  was  a  greater  retention  of  fat  when  human 
milk  was  given  than  when  cow's  milk  was  given. 

Fife  and  Veeder  ^  studied  two  cases  which  they  considered  to 
be  "infantile  atrophy"  and  found  that  the  fat  absorption  (Brugsch 
method  for  fat)  was  less  than  in  normal  infants.  Curiously  enough, 
the  per  cent  of  fat  absorbed  was  larger  when  large  amounts  of 
fat  were  given  than  when  small  amounts  were  given.  They  did 
not  find  that  the  carbohydrates  in  the  food  had  any  influence  on 
the  fat  absorption,  but  their  evidence  in  this  respect  is  incom- 
plete. 

VHayaslei:  Monatschr.  f.  Kinderh.,  1913,  jdi,  221. 
*Tobler  and  Bessau:  loc.  cU.  130. 

•  Wentworth:  Jour.  Am.  Med.  Assoc,  1907,  xlix,  204. 
<  Freund:  Biochem.  Zeitschr.,  1909,  xvi,  453. 

•  Bahrdt:  quoted  by  Tobler  and  Bessau,  loc.  cit. 

«  Meyer,  L.  F.:  Jahrb  f.  Kinderh.,  1910,  Ixxi,  379. 

'  Fife  and  Veeder:  Am.  Jour.  Dis.  Children,  1911,  ii,  19. 


30  METABOLISM  OF  FAT 

Wentworth  *  studied  the  fat  metabolism  (Folin-Wentworth 
method),  of  an  atrophic  infant  and  found  that  its  tolerance  for  the 
fat  in  himian  milk  was  much  greater  than  for  that  of  cow's  milk. 
His  results  were  confirmed  in  the  case  of  Kajitzki,^  He  was  un- 
able to  determine  whether  this  difference  in  the  absorption  of  the 
two  kinds  of  fat  was  due  to  a  difference  in  the  fats  themselves  or 
to  some  other  ingredient  in  the  milk. 

Hecht  ^  and  Reuss  ^  have  reported  cases  of  congenital  oblitera- 
tion of  the  bile  duct  with  normal  pancreas,  in  which  only  one-half 
of  the  fat  was  split.  In  Niemann's  case  ^  of  an  infant  with  ad- 
vanced biliary  cirrhosis  and  congenital  absence  of  the  bile  ducts, 
the  nitrogen  absorption  was  from  80%  to  93%  and  the  fat  absorp- 
tion from  28%  to  39%.  In  Koplik  and  Crohn's  case  ^  the  nitrogen 
absorption  was  86.2%  and  the  fat  absorption  48.4%.  Very  much 
less  than  the  normal  amount  of  fat  was  spht.  Similar  types  of 
stools  with  large  amounts  of  unsaponified  fat  have  been  observed 
by  us  clinically.^  These  figures  show  that  in  the  infant  as  well  as 
in  the  adult,  bile  is  necessary  for  the  normal  spUtting  and  absorp- 
tion of  fat. 

Tubercular  peritonitis  in  babies  is  primarily  a  disease  of  the 
Ijmaphatic  system  and  when  the  mesenteric  glands  become  caseous 
they  form  a  dam  beyond  which  the  fat  cannot  pass.  It  has  been 
shown  earlier  that  most  of  the  fat  is  normally  carried  by  the  lym- 
phatics to  the  blood  stream.  If  this  road  is  blocked  with  tuber- 
culous tissue,  it  is  reasonable  that  some  of  the  fat  should  be  lost 
from  the  body.  Talbot^  studied  cases  with  tuberculosis  of  the 
mesenteric  glands  and  found  that  in  all  cases  in  which  a  large 
proportion  of  these  glands  were  involved  there  was  a  loss  of  fat 
through  the  intestines.  Hecht  ^  believes  that  8%  of  the  fat  in 
the  stool  should  be  split,  and  considers  that  great  divergence  from 
this  amount  means  either  trouble  with  the  bile  or  pancreatic  juice. 
He  reports  the  case  of  a  seven  months,  premature  baby  which  was 
able  to  spht  only  53%  of  the  fat,  and  considers  this  to  be  due  to 

*  Wentworth:  Boston  Med.  and  Surg.  Jour.,  1910,  cbdi,  869,  and  Archives 
Int.  Med.,  1910,  vi,  420. 

2  Meyer,  L.  F. :  loc.  cU. 

*  Hecht:  "Die  Faeces  des  Sauglings  und  des  Kindes,"  Berlin-Wien,  1910, 
128. 

*  Reuss:  Case  of  Obliterated  Bile  Duct  (congenital)  Reported  in  Discus- 
sion,—Jahrb.  f.  Kinderh.,  Dec,  1908,  729. 

'Niemann:  Zeitschr.  f.  Kinderh.,  1912,  iv,  152. 

« Koplik  and  Crohn:  Am.  Jour.  Dis.  Children,  1913,  v.  36. 

^  Morse,  J.  L. :  Boston  Med.  and  Surg.  Jour.,  1910,  cbdi,  238. 

8  Talbot:  Am.  Jour.  Dis.  Children,  1912,  iv,  49.    (See  Uterature.) 

•Hecht:  loc.  cU. 


METABOLISM  OF  FAT  31 

weak  action  of  the  pancreatic  fat-splitting  enzyme,  which  pre- 
sumably is  not  completely  developed.  Finizio  *  explains  a  large 
amount  of  fat  in  the  stool  of  an  eleven  months'  old  baby  ill  with 
mumps  by  probable  trouble  in  the  pancreas.  In  this  case  75% 
of  the  dried  stool  was  fat,  and  of  this  only  7%  was  soaps,  while 
11%  was  fatty  acid  and  82%  neutral  fat. 

Czemy  ^  beUeves  that  babies  with  an  exudative  diathesis  can 
be  harmed  by  fat.  He  finds  that  an  increase  in  the  amount  of  fat 
in  the  food  will  bring  out  eruptions  on  the  skin.  Steinitz  and 
Weigert  ^  have  apparently  proved  the  correctness  of  this  assum- 
tion  by  a  metabolism  experiment. 

Towle  and  Talbot  *  studied  the  digestion  of  infants  ill  with  ec- 
zema and  found  that  in  a  large  number  of  cases  the  severity  of  the 
skin  eruption  bore  a  direct  relation  to  the  fat  in  the  food.  This  was 
by  no  means  the  case  in  all  instances,  but  there  was  a  sufl&cient 
number  to  substantiate  Czemy's  findings. 

There  is  no  doubt  that  large  amounts  of  fat  can  do  a  great  deal 
of  harm  to  most  babies.  Such  babies  come  under  two  classes, — 
those  which  have  a  normal  digestion  and  are  unable  to  digest  ex- 
cessive amounts  of  fat,  and  those  which  have  diminished  powers  of 
digestion  and  are  unable  to  digest  normal  amounts  of  fat.  So 
much  attention  has  been  paid  to  the  few  babies  that  are  unable  to 
digest  fat  that  we  are  apt  to  forget  that  most  babies  can  digest  fat 
within  reasonable  limits.  L.  F.  Meyer  ^  has  shown  in  Finkel- 
stein's  cUnic  that  when  fat  is  increased  in  the  food  of  normal 
healthy  babies  there  is  no  loss  of  fat  or  salts  from  the  body.  This 
dispels,  in  a  very  convincing  way,  the  false  impression  that  normal 
babies  are  unable  to  digest  fat.  Rowland  has  shown  in  a  recent 
investigation  (not  yet  published)  that  a  baby  can  be  fed  on  large 
quantities  of  fat  without  symptoms  of  indigestion  and  without 
acidosis. 

» Finizio:  Pediat.  Sept.,  1909,  674;  Rev.  in  Archiv.  f.  Kinderh.,  1910,  liv, 
461. 

» Czemy:  Part  I,  Monatschr.  f.  Kinderh.,  1906,  iv,  1;  ibid.,  Part  II,  1908, 
vi,  1;  ibid.,  Part  3,  1909,  vii,  1. 

»  Steinitz  and  Weigert:  Monatschr.  f.  Kinderh.,  1910,  ix,  385. 

*  Towle  and  Talbot:  Am.  Jour.  Dis.  Children,  1912,  iv,  219. 

» Meyer,  L.  F.:  Jahrb.  f.  Kinderh.,  April,  1910,  379. 


CHAPTER  III 

THE   DIGESTION   AND   METABOLISM   OF  CARBO- 
HYDRATES 

FERMENTS 

Saliva. — Zweifel  *  found  diastase  in  the  parotid  gland  of  the 
newly-born,  but  was  unable  to  find  it  in  the  submaxillary.  Ibra- 
him,^ after  prolonged  investigations,  found  it  in  both  the  parotid 
and  submaxillary  glands,  its  action  being  stronger  in  the  former 
than  in  the  latter.  Diastase  was  found  much  earlier  in  fetal  life 
in  the  parotid  than  in  the  submaxillary,  traces  being  found  in 
the  former  at  the  fourth  and  in  the  latter  at  the  sixth  month  of 
fetal  life.  The  diastase  of  the  parotid  is  the  earUest  digestive  fer- 
ment found  in  the  embryo. 

A  diastatic  ferment  can  always  be  found  in  the  saliva  of  healthy 
infants.^  The  diastatic  action  of  saliva  may  continue  in  the 
stomach  as  long  as  two  hours  after  feeding.* 

Stomach. — Ibrahim  ^  is  the  only  worker  who  has  examined  the 
gastric  mucous  membrane  of  the  newly-born  for  the  carbohydrate 
spUtting  ferments,  and  he  has  been  unable  to  find  either  lactase, 
maltase  or  invertin. 

Pancreas. — Moro  ^  was  able  to  demonstrate  the  presence  of  an 
amylolytic  ferment  in  the  pancreas  of  newly-born  babies  when  the 
pancreas  was  thoroughly  extracted,  and  thus  disproved  the  earUer 
work  of  Zweifel  and  Korowin.  Ibrahim  ^  never  failed  to  get  the 
ferment  in  a  six  months'  fetus  when  he  tested  the  action  of  the 

*  Zweifel:  Untersuchungen  iiber  den  Verdauungsapparat  der  Neugeborenen, 
Berlin,  1874. 

2  Ibrahim:  Verhandl.  d.  Gesell.  fiir  Kinderh.,  Koln,  1908,  p.  21. 

'Schiflfer:  Berl.  klin.  Wochenschr.,  1872,  ix,  353;  Korowin:  Jahrb.  f.  Kin- 
derh., 1875,  viii,  381;  Zweifel:  he.  cit.;  Schlossmann:  Jahrb.  f.  Kinderh., 
1898,  xlvii,  116;  Montagne:  Dissertation,  Leyden,  1889,  quoted  in  Czerny 
and  Keller, — "Des  Kindes  Ernahrung,"  etc.;  Schilling:  Jalirb.  f.  Kinderh., 
1903,  Iviu,  518. 

*Shaw:  Albany  Med.  Ann.,  1904,  xxv,  148. 

'  Ibrahim:  loc.  cU. 

•  Moro:  Jahrb.  f.  Kinderh.,  1898,  xlvii,  342. 
'Ibrahim:  he.  cit. 

32 


DIGESTION  OF  CARBOHYDRATES  33 

ferment  on  starch  meal.  He  was,  however,  unable  to  find  it  when 
he  tested  soluble  (i.  e.,  cooked)  starch. 

Ibrahim  was  unable  to  demonstrate  invertin  and  lactase  in  the 
pancreas  of  newly-born  or  older  babies,  but  he  was  usually  able  to 
demonstrate  maltase  in  the  newly-born  and  always  in  older  chil- 
dren.   Maltase  may  also  be  found  in  the  blood. 

Small  Intestine. — ^The  mucous  membrane  of  the  small  intes- 
tine contains  amylolytic  ferments. 

Lactase,  the  ferment  which  spHts  milk  sugar,  has  been  repeatedly 
found  in  the  mucous  membrane  of  the  small  intestine.^  Ibrahim 
always  found  it  in  the  small  intestine  and  meconium  of  newly-born 
babies,  but  was  imable  to  find  it  in  premature  infants.  He  says, 
however,  that  his  method  of  determining  lactase  is  not  capable  of 
demonstrating  small  amounts.  Lactase  is  more  abundant  in  young 
animals  than  in  the  adult. 

Pautz  and  Vogel  found  maltase,  the  ferment  which  splits  malt 
sugar,  in  the  small  intestine  of  infants. 

Invertin,  the  ferment  which  spUts  cane  sugar,  was  found  in  the 
secretions  of  the  small  intestine  of  the  newly-born  by  Miura  ^  and 
Ibrahim  was  always  able  to  demonstrate  its  presence  both  in  the 
intestinal  mucous  membrane  and  in  the  intestinal  contents  of  all 
fetuses. 

Large  Intestine. — It  is  difl&cult  to  wash  the  large  intestine  free 
from  meconium,  and  the  results  of  the  examinations  of  its  mucous 
membrane  are  variable,  as  the  tables  of  Miura,  Pautz  and  Vogel 
show.  It  is,  therefore,  impossible  to  say  whether  it  contains  fer- 
ments or  not. 

Stools. — Pottevin'  found  an  amylolytic  ferment  in  the  me- 
conium. Kerley,  Mason  and  Craig  ^  were  able  to  demonstrate  the 
presence  of  a  strong  amylolytic  ferment  in  the  stools  of  very  young 
babies,  the  possibility  of  the  bacterical  fermentation  of  starch 
being  excluded.  There  is  a  larger  amount  of  diatase  in  the  stools 
of  breast-fed  babies  than  in  those  of  the  bottle-fed,  which  Hecht  ^ 
beUeves  to  be  due  to  the  fact  that  the  intestinal  contents  of  the 
breat-fed  baby  pass  more  quickly  through  the  intestinal  canal 
than  do  those  of  the  bottle-fed  baby.  The  power  of  digesting 
starch,  while  occasionally  absent  is,  therefore,  almost  always  pres- 

1  Pautz  and  Vogel:  Zeitschr.  f.  Biol.,  1895,  xxxii,  304;  Weinland:  ibid.,  1899, 
xxxviii,  16;  Orbdn:  Prag.  med.  Wochenschr.,  1899,  xxiv,  427. 
"  Miura:  Zeitschr.  f.  Biol.,  1895,  xxxii,  266. 

*  Pottevin:  Compt.  rend,  de  la  Soc.  biol.,  1900,  lii,  589. 

*  Kerley,  Mason  and  Craig:  Arch.  Pediat.,  1906,  xxiii,  489. 

*  Hecht:  "Die  Faeces  des  Sauglings  und  des  Kindes,"  Berlin,  1910. 


34  DIGESTION  OF  CARBOHYDRATES 

ent  both  in  the  fetus  and  in  the  newly-born.  Hess  ^  always  found 
it  present  during  the  first  week  of  life,  the  amount  of  the  ferment 
increasing  with  the  age  of  the  infant.  Young  babies  are,  neverthe- 
less, able  to  adapt  themselves  to  a  food  rich  in  carbohydrates. 
There  is  according  to  Moro,^  a  rapid  increase  in  the  power  of 
digesting  starch  during  the  first  week  of  life.  The  baby,  therefore, 
has  a  power  of  digesting  starch  at  birth  which  gradually  increases 
in  strength  as  the  baby  grows  older.  It  can  digest  twice  as  much 
at  eight  months  as  it  can  at  birth,  and  at  twelve  months  as  much 
as  a  three  year  old  child.^  The  digestibility  of  starch  is  obviously 
dependent  on  the  way  it  is  prepared  and  cooked. 

The  question  whether  the  carbohjrrate-splitting  ferments  are 
affected  by  disease  has  been  answered  only  in  part.  Orb^n  *  found 
by  animal  experimentation  that  an  injured  intestinal  mucous  mem- 
brane contained  no  lactase,  and  that  the  stools  of  babies  ill  with 
enteritis  contained  no  lactase.  Langstein  and  Steinitz  ^  on  the 
other  hand,  always  found  lactase  in  the  stools  of  babies  ill  with 
enteritis,  whether  mild  or  severe,  acute  or  chronic.  Nothmann  ^ 
was  unable  to  demonstrate  lactase  in  the  stools  of  seven  premature 
babies  on  the  first  day  post  partum,  but  found  it  always  after  milk 
had  been  fed. 

FORMS  OF  CARBOHYDRATES 

The  forms  of  carbohydrates  commonly  used  in  infant  feeding 
may  be  divided  into  the  groups  given  in  the  following  table  (taken 
from  Reuss  0- 

»Hess:  Am,  Jour.  Dis.  Children,  1912,  iv,  205. 

"Moro:  Jahrb.  f.  Kinderh.,  1898,  xlvii,  342. 

« Finizio:  Rev.  d.  Hyg.  et  Med.  Inf.,  1909,  viii,  224. 

*Orbdn:  Prag.  med.  Wochenschr.,  1899,  xxiv,  427. 

*  Langstein  and  Steinitz :  Hoffmeister's  Beitrage,  1909,  vii,  575. 

•Nothmann:  Monatsschr.  f.  Kinderh.,  1909-10,  viii,  377. 

^  Reuss:  Wien.  med.  Wochenschr.,  1910,  Ix,  Nos.  28,  29,  30. 


DIGESTION  OF  CARBOHYDRATES 
TABLE   11 


35 


MUk  sugar  group 


Cane  sugar  group 


Malt  sugar  group 


Lactose  (milk  sugar) 

t 

Dextrose  +  Galactose 


Saccharose  (cane  sugar) 

I 

Dextrose  +  Levulose 


Starch  (Amylum) 

t 

Dextrin  (Amylo-dextrin) 

I 

Erythro  &  Achro-dextrin 

! 

Maltose  (malt  sugar) 

I 

Dextrose  +  Dextrose 


DIGESTION    OF   CARBOHYDRATES 

The  carbohydrates  are  broken  down  during  digestion  into  the 
simplest  forms  of  sugar,  the  mono-saccharides,  by  the  various  fer- 
ments described  above.  According  to  Rohmann  ^  a  considerable 
amount  of  the  di-saccharides  may  pass  into  the  intestinal  mucous 
membrane  and  there  be  split  into  mono-saccharides.  The  mono- 
saccharides are  carried  from  the  portal  vein  to  the  Uver,  where 
they  are  transformed  into  glycogen,  the  only  difference  being  that 
dextrose  is  more  easily  converted  than  levulose  or  galactose.^ 
Sugars  may  also  be  carried  into  the  blood  by  way  of  the  thoracic 
duct,^  but  ordinarily  very  little  is  absorbed  in  this  manner.  The 
pancreas  has  some  influence  on  this  process  because  extirpation 
of  the  pancreas  in  dogs  results  in  sugar  in  the  urine  and  interferes 
with  the  formation  of  glycogen  in  the  liver.  The  liver  actually 
has  the  property  of  forming  glycogen  from  sugar.  ^ 

The  purpose  of  the  splitting  of  the  poly-  and  di-saccharides  into 
mono-saccharides  is  to  prepare  them  for  use  inside  the  body,  be- 
cause the  unsplit  carbohydrates  are  not  burned  up  in  the  body,  but 
are  excreted  in  the  urine.  The  transformation  of  sugar  into  glyco- 
gen which  is  deposited  in  the  Uver  and  muscles,  is  of  great  impor- 
tance because  this  glycogen  can  be  converted  again  into  sugar 
according  to  the  needs  of  the  body. 

*  Rohmann:  Pfluger's  Arch.  1903,  xcv,  533. 

*  Alderhalden:  Textbook  of  Physiological  Chemistry,  London,  1908. 
»  Hendrix  &  Sweet:  Jour.  Biol.  Chem.,  1917,  xxxii,  299. 

*Grube:  Pfluger's  Arch.,  1905,  cvii,  490. 


36  DIGESTION  OF  CARBOHYDRATES      * 

There  is  normally  about  0.1  of  dextrose  in  the  blood.  The 
slightest  disturbance  of  the  regulating  apparatus  will  cause  a 
hjTperglycemia  which  results  in  glycosuria.  A  deficit  of  sugar  in 
the  blood  is  made  up  from  the  glycogen  deposits.^  *  The  mono- 
saccharides are  absorbed  more  quickly  than  the  di-saccharides.^ 
Niemann  ^  found  that  a  large  proportion  of  infants  respond  to 
food  with  an  alimentary  glycemia  but  that  the  intensity  varies 
within  a  wide  range.  The  highest  blood  sugar  (Bang's  micro- 
method)  is  invariably  found  in  infants  thriving  well  on  large 
amoimts  of  carbohydrate.  Other  infants  which  show  only  a  slight 
amount  of  alimentary  glycemia,  as  a  rule  do  not  thrive  on  car- 
bohydrates. According  to  Bergmark  ^  feeding  cane  sugar  leads  to 
a  greater  increase  in  blood  sugar  than  does  maltose  or  lactose,  and 
maltose  causes  a  greater  increase  than  lactose. 

A  large  part  of  the  digestion  and  absorption  of  the  carbohydrates 
takes  place  in  the  upper  part  of  the  small  intestine.^  Splitting 
and  absorption  may  also  take  place  in  the  large  intestine.^ 

The  bacteria  of  the  stomach  and  intestines  attack  not  only 
cellulose  but  other  carbohydrates  as  well.  The  decomposition  of 
the  carbohydrates  by  means  of  bacteria,  in  general,  is  not  very 
extensive  and  depends  very  much  on  the  external  conditions.  The 
products  formed  by  their  action  are  chiefly  lactic  acid,  acetic  acid, 
formic  acid,  butjo-ic  acid  and  alcohol  with,  in  addition,  the  evolu- 
tion of  carbon  dioxide,  hydrogen,  and  methane.^  In  abnormal 
conditions  the  bacteria  probably  play  a  much  more  important  part 
in  the  breaking  down  of  carbohydrates. 

Little  or  no  sugar  can  be  found  in  the  stools  under  normal  condi- 
tions, but  when  the  food  passes  quickly  through  the  intestinal 
canal,  as  it  does  when  the  peristalsis  is  increased  as  the  result  of 
disease  or  indigestion,  sugar  may  be  found  in  the  stools  (Hecht). 
Usually,  only  the  products  of  the  decomposition  of  sugar  can  be 
isolated. 

Hedenius*  fed  babies  on  milk  mixed  with  wheat  flour,  oat 

^Langstein-Meyer:  Sauglings  Emahnmg  und  Sauglingsstoffwechsel,  Wie8- 
baden  1910. 

*H6don:  Compt.  rend,  de  la  Soc.  de  Biol.,  1900,  29;  Nagano:  Pfluger's 
Archiv.,  1902,  xc,  389;  Rohmann:  Chem.  Bei.,  1895,  xxviii,  2506. 

*  Jahrb.  f.  Kinderh.,  1916,  Ixxxiii,  p.  1. 

*  Bergmark:  Jahrb.  f.  Kinderh.,  1914,  Ixxx,  373. 

*  London  and  Polowzowa:  Zeitschr.  f.  physiol.  Chem.,  1906,  xUx,  328. 

*  Reach:  Arch.  f.  exp.  Path  u.  Pharm.,  1902,  xlvii,  230;  SchOnbom:  Diss. 
Wurzburg,  1897;  Pehu  and  Porcher:  Rev.  d'Hyg.  et  de  Med.  Inf.,  1910,  ix,  1. 

'Tappeiner,  H.:  Zeitschr.  f.  Biol.,  1883,  xix,  228. 

*  H^enius:  Ueber  das  Schicksal  der  Kohlehydrate  im  Sauglingsdarm. 


DIGESTION  OF  CARBOHYDRATES  37 

gruel  or  Keller's  malt  extract  and  measured  the  amount  (rf 
carbohydrate  ingested,  the  amount  found  in  the  stools,  and  the 
acidity  of  the  stools.  He  found  less  carbohydrate  in  the  stools 
when  simple  cereals  were  used  than  when  the  more  compli- 
cated mixtures  were  given.  He  also  found  that  the  more  car- 
bohydrate there  was  in  the  stool,  the  greater  was  its  acidity.  He 
never  found  more  than  3%  of  the  ingested  carbohydrate  in  the 
stools. 

Raczynski  ^  has  shown  that  in  babies  sick  with  what  he 
calls  "dyspepsia  intestinalis  acida  lactorum,"  the  acidity  of 
the  intestinal  contents  is  increased  and  the  utilization  of  fat 
diminished. 

Talbot  and  Hill  ^  found  in  their  case  (J.  P.),  that  an  increasing 
amount  of  lactose  in  the  food  did  not  appreciably  influence  the 
titratable  acidity  of  the  stool  until  a  diarrhea  commenced.  The 
acidity  then  increased  500%  and  lactic,  acetic,  succinic  and  butyric 
acids  were  found  to  be  present.  This  fact  seemed  to  indicate  that 
the  acid-forming  bacteria  played  an  important  part  in  the  brealdng 
down  of  the  sugar.  This  assumption  finds  support  in  the  studies 
of  Bahrdt  and  Bamberg,^  who  concluded  that  acetic  acid  was 
more  effective  in  causing  diarrhea  than  the  other  volatile  fatty 
acids,  and  that  it  was  undoubtedly  formed  in  the  small  intestine 
through  the  agency  of  the  intestinal  bacteria.  "*  Bahrdt  and  Mc- 
Lean ^  found  that  the  volatile  fatty  acids  in  the  stools  of  infants 
fed  on  breast  milk  increased  when  sugar  was  added  to  the  milk. 
The  same  is  true  of  bottle  fed  infants  with  acute  digestive  dis- 
turbances. They  are  not,  however,  always  due  to  sugar  but  may 
also  be  due  to  the  decomposition  of  fat. 

Keller®  has  shown  that  carbohydrates  make  the  digestion  of 
protein  more  complete.  Talbot  and  Hill  ^  have  recently  confirmed 
these  findings.  A  possible  explanation  of  the  protein-sparing  ac- 
tion of  carbohydrates  may  be  found  in  the  work  of  Kendall  and 
Farmer ''  on  the  metabolism  of  bacteria.  They  found  that  in  the 
test-tube,  when  sugar  was  present  in  the  food,  less  ammonia  nitro- 
gen was  formed  than  when  sugar  was  absent.    If  the  results  ob- 

'  Raczynski:  Wien.  klin.  Wochenschr,  1903,  xvi,  342. 

2  Talbot  and  HiU:  Am.  Jour.  Dis.  Children,  1914,  viu,  218;  Weill  &  Du- 
fourt:  La.  Nourrisson,  1914,  ii  65. 

'Zeitschr.  f.  Kinderh.,  1912,  iii,  322. 

*  Edelstein  and  Csonka:  Biochem.  Zeltschr.,  1912,  xlii,  372. 

» Bhardt  and  McLean:  Zeltschr.  f.  Kinderh.,  1914,  xi,  143. 

'Keller:  "Des  Kindes  Ernahrung,"  etc., — loc.  cU. 

">  KendaU  and  Farmer:  Jour.  Biol.  Chem.,  1912,  xu,  13;  1912,  Nos.  1,  2  and 
3;  1912-13,  xiii.  63. 


38  METABOLISM  OF  CARBOHYDRATES 

tained  in  the  test-tube  are  applicable  to  the  intestinal  canal,  the 
reason  that  more  nitrogen  is  retained  in  the  body  when  sugar  is 
present  is  not  because  the  sugar  makes  the  nitrogen  more  easily 
absorbable,  but  because  the  intestinal  bacteria  use  the  sugar  in 
preference  to  the  protein  and  form  less  nitrogen  to  be  carried  away 
in  the  stools.  In  other  words,  the  bacteria  leave  a  larger  amount  of 
nitrogen  for  absorption  than  when  they  grow  on  a  sugar-free  pro- 
tein. Cathcart  ^  and  Janney  ^  suggest  that  carbohydrates  are  es- 
sential to  protein  synthesis.  Kocher  ^  showed  that  lactic  acid  also 
spared  protein.  His  work  adds  support  to  the  possibility  that  the 
combination  of  ammonia,  a  product  of  protein  metabolism  with 
the  dissociation  products  of  glucose  to  form  new  proteins,  is  the 
mechanism  by  which  this  sparing  action  is  effected. 

Albertoni  *  and  H6don  ^  found  that  sugars  have  a  purgative 
action  when  they  are  given  in  large  enough  amounts.  This  action 
is  more  marked  when  they  are  taken  in  concentrated  solution. 
All  sugars  have  this  action,  the  difference  between  them  being 
only  in  degree.  They  found  that  glucose  and  cane  sugar  are  much 
more  quickly  absorbed  than  lactose,  and  that  glucose  has  less  of  a 
purgative  action  than  the  cane  sugar.  According  to  the  extensive 
experiments  of  Rohmann  and  Nagano*  saccharose  is  absorbed 
more  quickly  than  maltose. 

Block  ^  reports  instances  of  infants  fed  on  an  exclusive  carbo- 
hydrate diet,  who  seemed  to  be  fat  and  well,  but  suddenly  be- 
came ill  and  died.    They  had  either  sclerema  or  oedema. 

METABOLISM   OF   CARBOHYDRATES 

Numerous  observations  ^  have  shown  that  when  milk  sugar  is 
injected  directly  into  the  circulation  it  may  be  completely  re- 
covered in  the  urine.  Grosz  ^  was  never  able  to  detect  milk  sugar 
in  the  urine  of  healthy  babies,  but  found  it  in  the  urine  of  those 
suffering  with  gastrointestinal  disease,  in  which  there  was  pre- 

*  Cathcart:  The  Physiology  of  Protein  MetaboKsm,  London,  1912,  121. 

*  Janney:  Jour.  Biol.  Chem.,  1916,  xxiv,  30. 
'Kocher:  Jour.  Biol.  Chem.,  1916,  xxv,  571. 

*  Albertoni:  Arch.  ital.  de  Biol.,  xv,  xviii,  xxx,  xxxv,  xxxviii,  xl. 

«  Hedon:  Compt.  rend,  de  la  Soc.  de  Biol.,  1899,  884;  ibid.,  1900,  29  and  87. 

"  Rohmann  and  Nagano:  quoted  by  Hammarsten  and  Mandel,  "Textbook 
of  Physiological  Chemistry,"  New  York,  1912,  509. 

"  Block:  Ugeskrift  f.  Laeger,  1917,  Ixxix,  no.  8,  Abstr.  Jour.  A.  M.  A.> 
1917,  Ixviii,  1444. 

8  Voit:  Deutsch.  Arch,  fur  klin.  Med.,  1897,  Iviii,  523. 

9  Grosz:  Jahrb.  f.  Kinderh.,  1892,  xxxiv,  83. 


METABOLISM  OF  CARBOHYDRATES  39 

sumably  an  absence  of  lactase  in  the  intestine.  Langstein  and 
Steinitz  ^repeated  Grosz's  experiments  and  in  certain  instances 
found  lactase  in  the  stools  at  the  same  time  that  sugar  was  being 
excreted  in  the  urine.  This  sugar  was,  moreover,  not  always  lac- 
tose, but  sometimes  galactose,  one  of  the  products  of  the  splitting 
of  lactose.  They  tried  to  explain  this  as  follows: — That  some  of 
the  sugar  passes  through  areas  of  the  intestinal  wall  made  abnormal 
by  functional  or  anatomical  lesions  before  it  is  completely  broken 
up  and  it  is  excreted  in  the  urine  as  an  intermediary  product  of 
metabolism. 

Mendel  and  Keliner  ^  have  shown  that  when  cane  sugar  is  in- 
troduced subcutaneously  into  dogs  or  cats  in  doses  of  one  to  two 
grams  per  kilogram  of  body  weight  it  is  not  completely  recovered 
in  the  urine.  The  quantity  excreted  amounts  as  a  rule  to  more 
than  65%  of  that  introduced.  The  excretion  begins  within  a  few 
minutes  and  is  usually  completed  within  thirty-six  hours.  Fisher 
and  Moore  '  draw  attention  to  the  possibility  that  the  sugar  thus 
introduced  may  be  excreted  through  the  walls  of  the  alimentary 
tract  and  there  be  digested.  These  views  are  supported  by  Jappelli 
and  D'Errico,^  who  conclude  from  their  experiments  on  dogs  that 
when  cane  sugar  is  introduced  directly  into  the  circulation  the 
quantity  eliminated  in  the  urine  is  never  equivalent  to  the  amount 
injected.  This  causes  both  glycosuria  and  saccharosuria,  the  for- 
mer disappearing  first.  The  blood  has  no  power  of  converting 
cane  sugar.  According  to  these  writers  cane  sugar  introduced 
intravenously  is  eliminated  into  the  alimentary  tract  through  the 
gastric  mucosa,  the  salivary  glands  and,  to  an  insignificant  degree, 
through  the  bile.  The  subsequent  fate  of  this  component  is 
obvious. 

In  the  year  1906,  Finkelstein  published  the  first  of  a  series  of 
papers  ^  which  have  caused  much  discussion  as  to  the  etiology  of 
the  digestive  disturbances  of  infancy.  In  the  first  place  he  opposed 
Czemy's  teachings  as  to  the  harmfulness  of  fat  in  infant  feeding. 
He  taught  that  bacteria  played  no  part  in  the  etiology  of  the 

*  Langstein  and  Steinitz:  Moffmeister's  Beitrage,  1906,  vii,  575. 

*  Mendel  and  Keliner:  Am.  Jour.  Physiol.,  1910,  xxvi,  396. 
'Fisher  and  Moore:  Am.  Jour.  Physiol.,  1907,  xix,  314. 

^  JappeUi:  Ref.  Maly's  Jahresbericht  fiir  Tierchemie,  1905,  xxxv,  79. 

« Finkelstein:  Verhandl.  Gesellsch.  f.  Kinderh.  (Stuttgart),  1906,  xxiii,  117; 
Jahrb.  f.  Kinderh.,  1907,  Ixv,  1  and  263;  Jahrb.  f.  Kinderh.,  1908,  Ixviii,  521; 
Deutsch.  med.  Wochenschr.,  1909,  xxxv,  191;  Finkelstein  and  Meyer:  Jahrb. 
f.  Kinderh.,  1910,  bod,  525  and  Berliner  khn.  Woch.,  1910,  xlvii,  1165.  For 
literature  and  an  excellent  discussion  of  the  subject,  see  chapter  on  "Sugar 
in  the  Young  "  in  Allen, — "Glycosuria  and  Diabetes,"  Harv.  Univ.  Press,  1913. 


40  METABOLISM  OF  CARBOHYDRATES 

digestive  disturbances  of  infancy  and  that  the  sugars  produced 
sjonptoms  of  intoxication.  He  also  undertook  to  prove  that  the 
albumens  were  quite  harmless.  He  considered  that  the  most  acute 
form  of  disease  of  the  digestive  tract,  that  accompanied  by  stupor, 
fever,  and  sugar  in  the  urine,  was  the  result  of  an  intoxication 
caused  by  sugar.  He  blamed  lactose  for  the  poisoning  of  the 
system,  and  claimed  that  instantaneuos  benefit  and  cure  resulted 
from  the  complete  withdrawal  of  sugar.  Schaps  ^  and  Leopold  and 
Reuss  ^  also  thought  that  lactose  and  other  sugars  were  pjTogenic. 
In  1909,  Finkelstein  said, — "It  is  possible,  with  the  certainty  of 
an  experiment,  by  giving  a  dose  of  sugar  (for  example  100  grams 
of  a  12.5%  lactose  solution),  to  an  infant  with  bowel  trouble  to 
force  up  the  previously  afebrile  temperature  into  fever,  practically 
with  the  same  certainty  as  if  one  should  give  it  a  dose  of  tubercu- 
lin." His  * '  eiweissmilch ' '  was  prepared  to  cure  sugar  intoxications. 
He  apparently  overlooked  the  fact  that  it  contained  13^%  or 
more  of  the  lactose  which  he  considered  so  poisonous  in  this  con- 
dition. As  his  theories  developed,  he  decided  that  the  sugar  in- 
toxication was  not  due  to  a  sugar  injury  alone,  but  to  the  actions 
of  salts,  especially  the  chlorine-ion  combination  with  sodium. 
Friberger,^  Schloss,^  Cobliner,^  and  Nothmann,^  confirmed  Meyer's 
statements  concerning  the  pyrexial  effects  of  sodium-halogen  com- 
pounds, while  Rosenthal  ^  found  that  in  animals  neither  salt  nor 
sugar  had  any  specific  pyrogenic  action. 

In  1910  Finkelstein  and  Meyer  ascribed  intestinal  irritation  to 
abnormal  fermentations.  They  stated  that  casein  was  never 
harmful  and  that  it  prevented  or  diminished  acid  fermentation. 
They  stated,  on  the  other  hand,  that,  as  Czemy  pointed  out,  fat 
was  more  dangerous,  but  claimed  that  it  was  only  harmful  in  a 
bowel  irritated  by  carbohydrate  fermentation.  They  admitted,  at 
this  time,  that  human  milk  was  the  best  food  to  give  in  these  condi- 
tions, thus  abandoning  their  earUer  contention  that  lactose  (which 
is  present  in  large  amounts  in  human  milk)  is  poisonous. 

Helmholz  *  found  that  5%  solutions  of  sodium  chloride,  bromide, 
and  iodide  injected  into  rabbits  subcutaneously  in  quantities  of 

1  Schaps:  Verhandl,  Gesellsch.  f.  Kinderh.,  1906,  xxiii,  153;  Berliner  klin. 
Wochenschr.,  1907,  xliv,  597. 

*  Leopold  and  Reuss:  Monatschr.  f.  Kinderh.,  1909-10,  viii,  1  and  453. 

'  Friberger:  Miinch.  med.  Wochenschr.,  1909,  Ivi,  1946. 

*Schloss:  Biochem.  Zeitschr.,  1909,  xviii,  14. 

'  Cobliner:  Zeitschr.  f.  Kinderh.,  ii,  429. 

'  Nothmann:  Zeitschr.  f.  Kinderh.,  i,  73. 

»  Rosenthal:  Jahrb.  f.  Kinderh.,  1909,  Ixx,  123. 

*Helmholtz:  Arch,  of  Internal  Medicine,  1911,  vii,  468. 


METABOLISM  OF  CARBOHYDRATES  41 

from  ten  to  twenty-five  cubic  centimeters  caused  no  rise  of  temper- 
ature in  the  great  majority  of  experiments.  Sodium  chloride  pro- 
duced a  slight  rise  in  temperature  when  given  intravenously  in  high 
concentration.  A  1%  solution  of  sodium  chloride  may,  in  excep- 
tional instances,  produce  a  febrile  rise  in  temperature  when  given 
by  mouth.  Schlutz  *  confirmed  these  findings;  he  found  that  lac- 
tose alone  possesses  no  distinct  pyrogenic  action,  but  that  it  may 
affect  the  temperature  if  it  is  given  in  combination  with  a  sodium 
salt  when  the  intestinal  tract  is  diseased. 

Allen  ^  studied  the  effects  of  sugars  in  young,  nursing  animals 
and  found  that  in  no  instance  were  there  any  symptoms  of  the 
intoxicating  action  of  sugar,  even  when  the  animals  received  so 
much  sugar  by  mouth  that  they  had  vomiting  and  diarrhea.  He 
found,  furthermore,  that  subcutaneous  injections  of  glucose  had  a 
very  beneficial  action  on  animals,  even  when  they  had  glycosuria 
and  were  doing  badly.  The  evidence  at  hand  is  opposed  to  the  be- 
lief that  sugar  has  any  specific  intoxicating  effect  or  acts  as  a  food 
poison  and  is  in  favor  of  the  theory  ^  that  it  is  a  medium  of  growth 
for  bacteria  in  which  they  can  develop  sufficiently  to  harm  the  body 
either  by  their  own  activity  or  by  the  products  which  result  from 
their  activity. 

The  limits  of  assimilation  of  the  different  sugars  vary  and  are 
given  as  follows: 

Grape  sugar:  In  babies,  about  5  grams  per  kilogram  (Langstein 
and  Meyer). 

Grape  sugar:  In  one  month  baby,  8.6  grams  per  kilogram 
(Greenfield).* 

Galactose:  No  accurate  data. 

Levulose:  (Lower  for  babies  than  adults),  one  gram  per  kilogram 
(Keller). 

Maltose:  Over  7.7  grams  per  kilogram  (Reuss). 

Lactose:  From  3.1-3.6  grams  per  kilogram  (Grosz). 

Porter  and  Dunn  ^  state  that  as  much  as  120  gm.  of  lactose  may 
be  added  to  the  food  of  infants  with  indigestion  in  twenty-four 
hours  without  appearing  in  the  urine  in  sufficient  quantities  to 
be  determined  quantitatively. 

Cane  sugar:  Probably  about  the  same  as  lactose  (Reuss). 

The  main  facts  which  are  apparently  true  about  the  metabolism 

» Schlutz:  Am.  Jour.  Dis.  Children,  1912,  iii,  95. 

'Allen:  "Glycosiuia  and  Diabetes,"  Harvard  Univ.  Press,  1913. 

»  Escherich:  Deutsche  Klinik,  1902,  vii,  126. 

*  Greenfield:  Jahrb.  f.  Kinderh.,  1903,  Iviii,  666. 

6  Porter  and  Dtinn:  Am.  Jour.  Dis.  Ch.,  1915,  x,  77. 


42  METABOLISM  OF  CARBOHYDRATES 

of  carbohydrates  in  infancy  are: — carbohydrates  are  absorbed  up 
to  a  certain  point,  lactose  being  absorbed  more  slowly  than  the 
other  di-saccharides.  Up  to  a  certain  point  lactose  and  maltose 
increase  the  retention  of  nitrogen,  but  apparently  have  no  or  only 
slight  beneficial  effect  on  the  retention  of  ash  or  the  absorption 
of  fats.  Carbohydrates  may  increase  the  retention  of  sodium  and 
water.  The  large  pasty  infant  fed  on  a  high  carbohydrate  mixture 
is  an  example  of  the  effect  of  a  large  retention  of  water.  Carbo- 
hydrates may  also  be  deposited  in  the  body  in  the  form  of  fat. 
When  too  much  sugar  is  given  to  an  infant  there  is  a  marked  in- 
crease in  the  acidity  of  the  intestinal  canal  and  an  increased 
peristalsis,  which  washes  the  irritating  food  out  of  the  bowels  as 
quickly  as  possible.  Large  amounts  of  fat,  protein  and  ash  are 
carried  out  in  the  stools,  resulting  in  a  diminished  absorption  and 
retention  of  these  food  components.  Some  of  the  elements  of  ash 
are  lost  to  a  greater  extent  than  others  and  their  loss  may  be  so 
large  that  the  output  surpasses  the  intake.  Under  such  circum- 
stances the  organism  is  drained  of  part  of  its  own  mineral  content. 

Starches  act  in  the  same  manner  as  the  other  carbohydrates 
except  that  having  a  more  complicated  molecule,  they  go  through 
one  more  step  in  the  process  of  their  conversion  into  a  mono- 
saccharide. 

Marriott  iu  a  paper  presented  before  the  American  Medical 
Association,  June,  1919,  shows  conclusively  that  Finkelstein's 
theories  have  no  scientific  background.  Marriott's  conclusions 
should  be  consulted-  on  the  publication  of  his  paper. 


CHAPTER  IV 
THE  DIGESTION  AND  METABOLISM  OF  PROTEIN 

FERMENTS 

The  saKva  of  man  was  shown  to  contain  a  proteolytic  ferment 
by  Ed.  Miiller,^  but  up  to  date  such  a  ferment  has  not  been  found 
in  infants. 

Pepsin  was  first  demonstrated  in  the  mucous  membrane  of  the 
infant's  stomach  by  Zweifel  ^  and  later  Langendorff  *  extracted 
it  with  HCl  from  the  stomach  of  a  fetus  of  four  months,  at  which 
time  there  is  microscopic  evidence  of  glandular  formation.  The 
amount  of  pepsin  increases  with  the  age  of  the  baby  up  to  the 
third  month,  and  from  then  on  remains  constant  in  amount;  it  is 
present  in  larger  quantities  in  bottle-fed  babies  than  in  breast-fed 
babies.^  Pechstein  ^  examined  the  urines  of  babies  at  different 
ages  and  under  different  conditions  and  found  that  aU  babies 
excrete  pepsin  and  rennin  in  their  urine  from  the  day  of  their 
birth  onward.  These  ferments  are  present  only  in  the  form  of 
their  pro-ferments.  They  are  found  in  minute  quantities  in  the 
early  days  of  life  and  increase  in  amount  up  to  the  end  of  the  first 
year,  at  which  there  is  about  time  one-twentieth  as  much  as  in  the 
adult.  The  urine  of  the  artificially-fed  baby  contains  more  than 
does  that  of  the  breast-fed  baby.  During  an  acute  disturbance 
of  digestion  they  are  as  abundant  as  in  health,  but  during  chronic 
diseases  they  seem  to  be  slightly  diminished  in  amount.  When 
pepsin  and  rennin  are  fed  to  a  baby,  no  traces  are  found  in  the 
urine,  and  there  is  no  increase  in  the  amount  of  rennin  in  the 
stool.  The  ferments  must,  therefore,  have  been  destroyed  in  the 
upper  intestine  or  neutralized  in  the  blood  stream.  If  the  intestinal 
mucous  membrane  is  damaged,  the  ferments  appear  in  the  urine. 

Rennin.  and  hydrochloric  acid  are  found  in  the  first  days  of 

» Ed.  Mullet:  Verhandl.  d.  Cong,  fur  inn.  Med.,  1908,  676. 

*  Zweifel:  Untersuchungen  iiber  den  yerdauungsapp>arat  der  Neugeborenen, 
Berlin,  1874. 

*  Laiigendorff :  Arch,  fiir  Anat.  u.  Physiol.,  1879,  95. 
'Rosenstem:  Berl.  klin.  Wochenschr.,  1908,  542. 
•Pechstein:  Zeitschr.  f.  Kinderh.,  1911,  i,  365. 

43 


44  DIGESTION  OF  PROTEIN 

life.^  Rennin  has  been  demonstrated  in  sterile  meconium  ^  and 
a  rennin  fennent  which  acts  independently  of  the  stomach  and 
pancreas  ^  has  been  found  in  the  stool. 

Trypsin. — Zweifel  demonstrated  trypsin  in  the  pancreatic  ex- 
tracts of  new-bom  babies,  and  Langendorff  found  it  at  the  be- 
ginning of  the  fifth  month  of  fetal  life.  Ibrahim  ^  showed  that 
when  absolutely  fresh  material  was  used  only  the  pro-ferment 
trypsinogen  is  present  in  the  pancreas  of  the  fetus,  but  that  small 
amounts  of  trypsin  may  be  present  in  the  pancreas  of  older  chil- 
dren. This  can  be  markedly  increased  by  activating  it  with  enter- 
okinase.  The  pro-ferments  are  apparently  activated  by  bacteria, 
which  are,  of  course,  not  present  in  the  intestinal  canal  of  the  fetus. 
He  was  able  to  demonstrate  trypsinogen  in  a  six-months-old  fetus. 

Trypsin  is  found  in  the  feces  in  small  amounts  in  health  and  in 
large  amounts  during  diarrhea  caused  either  by  drugs  or  disease. 
Sterile  meconiimi  has  the  property  of  dissolving  gelatine.^  Hecht  ^ 
demonstrated  trypsin  in  the  stools  of  babies  as  early  as  the  first 
day  of  fife. 

Wienland^  found  anti-pepsin  in  the  stomach  and  anti-trypsin 
in  the  intestinal  mucous  membranes;  he  believed  that  their  func- 
tion was  to  prevent  auto-digestion.  Cohnheim  ^  believes  that  anti- 
trypsin is  identical  with  enterokinase  and  that  in  small  amounts  it 
activates  trypsin,  and  in  large  amounts  prevents  its  action. 

Enterokinase. — The  ferment  which  activates  trypsinogen  was 
first  found  by  Ibrahim,  who  extracted  it  from  the  intestinal  mu- 
cous membrane  of  new-born  babies,  and  from  meconium.  It  is 
most  active  in  the  lower  third  of  the  intestine  in  the  majority 
of  instances;  it  may  also  be  obtained  from  the  mucous  membrane 
of  the  large  intestine.  It  apparently  first  appears  in  embryonic 
life  at  the  same  time  that  trypsin  is  found  in  the  pancreas. 

Secretin,  according  to  Bayliss  and  Starling,^  is  necessary  for 
the  activation  of  the  pancreas.  It  may  be  extracted  from  the 
intestinal  mucous  membrane;  it  is  not  destroyed  by  heat,  and 
belongs  to  the  group  of  hormones.  When  injected  intravenously 
it  causes  a  flow  of  pancreatic  juice  in  about  one  minute.    Ibrahim 

^  Szydlowski:  Jahrb.  f.  Kinderh.,  1892,  xxxiv,  411, 

2  Pottevin:  Compt.  rend,  de  la  Soc.  de  Biol.,  1900,  lii,  589. 

8  Th.  Pfeiffer:  Zeitschr.  f.  Exp.  Path.  u.  Therap.,  1906,  iii,  381. 

*  Ibrahim:  Gesellschaft  Deutscher  Naturforscher  und  Artzte  in  Coin,  1908. 

^Pottevin:  loc.  cit. 

•Hecht:  Wien.  klin.  Wochenschr.,  1908,  xxi,  1550. 

»Wienland:  Zeitschr.  f.  Biol.,  1903,  xliv,  pt.  I. 

"Cohnheim:  Nagel's  Handbuch  d.  Physiol.,  1907,  ii,  5Q7. 

'  Bayliss  and  Starling:  Jour.  Physiol.,  1902,  xxviii,  325. 


DIGESTION  OF  PROTEIN  45 

and  Gross  *  found  it  in  babies  who  died  at  birth,  but  not  in  pre- 
mature babies.  Wentworth  ^  found  it  absent  or  present  only  in 
small  amounts  in  newly-born  babies.  He  found  definite  but  weak 
action  in  a  premature  baby  which  had  Uved  three  weeks.  Older 
babies,  which  had  died  of  other  diseases  than  those  of  the  digestive 
tract,  all  showed  a  definitely  active  secretin.  Halhon  and  Le- 
queux  '  found  secretin  in  the  upper  part  of  the  intestine  of  two 
newly-born  babies,  but  were  unable  to  find  it  in  the  lower  part  of 
the  intestine.  They  obtained  the  same  results  in  a  five  months' 
fetus.    There  is  no  record  of  secretin  being  found  in  the  feces. 

Erepsin  was  first  demonstrated  in  the  intestinal  mucous  mem- 
brane by  Cohnheim.^  It  changes  albumoses  and  peptones  very 
rapidly  into  amino-  and  diamino-acids,  so  that  the  Biuret  reaction 
disappears.  It  has  no  action  upon  the  native  albumens  with  the 
exception  of  casein.  It  is  present  in  all  babies,  including  pre- 
mature infants.^ 

Lust^  found  an  anti-proteolytic  ferment  in  the  blood  of  an 
infant  fourteen  days  old,  which  had  the  same  anti-tryptic  power  as 
that  in  the  blood  of  an  infant  of  one  year.  There  is  no  increased 
formation  of  this  ferment  in  digestive  disorders,  while  in  some 
cases  of  alimentary  intoxication,  in  which  there  is  loss  of  protein 
from  the  body,  there  is  an  increased  amount  of  the  anti-ferment. 

Mitra  ^  was  unable  to  find  nuclease  or  connectivase  which  could 
digest  muscle  fibre  and  connective  tissue  in  the  stomach  of  an 
infant  twelve  months  old,  but  found  both  ferments  in  a  child  of 
fifteen  months.  Rossi  ^  measured  the  stimulating  effect  of  saliva 
on  the  pepsin  digestion  by  the  Mett  method.  He  found  it  greatest 
in  the  early  stages  of  digestion  but  it  became  almost  imperceptible 
at  the  end  of  four  hours.  Wakabayashi  and  Wohlgemuth  ^  found 
that  the  large  intestine  contains  erepsin,  nuclease,  hemolysin  and  a 
fibrin  enzjnne. 

The  changes  which  protein  undergoes  during  digestion  may  be 
briefly  enumerated  as  follows: 

When  it  is  ingested  it  is  spht  and  hydrolyzed  by  the  various 

» Ibrahim  and  Gross:  Jahrb.  f.  Kinderh.,  1908,  Ixviii,  232. 

*  Wentworth:  Jour.  Am.  Med.  Assoc,  1907,  119,  204. 

'  Hallion  and  Lequeux:  Compt.  Rend,  de  la  Soc.  de  Biol.,  Paris,  1906,  bd,  33. 
*Cohnheim:  Zeitschr.  f.  Physiol.  Chemie.  Mitteilungen  liber  das  Erepsin, 
1902,  XXXV,  134.    Notiz  iiber  das  Erepsin,  1906,  xlvii,  286. 
'  Langstein:  Jahrb.  f.  Kinderh.,  1908,  Ixvii,  9. 

•  Lust:  Munchen  Med.  Wochenschr.,  Ivi,  2047-2051. 
'  Mitra:  Folia  clinica,  iii,  274. 

'  Rossi:  Arch.  Fisiol.,  viii,  484;  from  Zentralbl.  Biochem.  u.  Biophys.,  ii,  436. 
•Wakabayashi  and  Wohlgemuth:  Internat.  Beitr.  Path.  Therap.,  ii,  519. 


46  DIGESTION  OF  PROTEIN 

ferments  in  a  definite  sequence.  Pepsin  reduces  it  into  albumoses 
and  peptones.  Trypsin  and  erepsin  then  split  these  bodies  further 
into  amino  acids,  with  an  intermediary  stage  of  polypeptides.  The 
end  products  of  protein  digestion  are  amino  acids  and  their  combi- 
nations. 

Folin  and  Denis  ^  and  Van  Slyke  and  Meyer  ^  showed  that  the 
amino  acids  are  absorbed  as  such  from  the  alimentary  tract.  The 
evidence  adduced  by  these  observers  that  the  amino  acids  reach 
the  blood  stream  as  amino  acids  and  are  carried  to  the  tissues  to  be 
used  in  the  formation  of  new  tissue  or  to  be  disintegrated  with  the 
resultant  production  of  the  end  product  urea,  has  been  strength- 
ened by  the  work  of  London.^  Recent  investigations  on  dogs 
seem  to  prove  that  the  amino  nitrogen  is  absorbed  both  through 
the  blood  vessels  and  the  l3niiphatic  system.*  During  digestion  the 
amount  of  amino-nitrogen  increases  not  only  in  the  portal  blood 
but  also  in  the  peripheral  circulation. 

CASEIN   CURDS 

Twenty-eight  years  ago  Biedert  ^  published  the  first  of  a  series 
of  papers,  in  which  he  tried  to  show  that  many  of  the  disturb- 
ances of  digestion  in  infancy  were  due  to  difficulty  in  digesting 
casein.  He  beheved  that  the  bean-like  masses  which  appeared 
in  the  stools  of  artificially-fed  babies  during  disturbances  of  di- 
gestion were  either  casein  or  one  of  its  derivatives.  He  found 
that  their  microscopic  appearance  was  similar  to  that  of  coagulated 
casein  and  that  they  turned  pink  with  Million's  reagent.  Weg- 
scheider,®  Uffelmann,^  Escherich,^  and  Fr.  Muller^  were  unable  to 
confirm  Biedert's  assumption  and  concluded  from  their  own  ex- 
periments that  the  "so-called  casein  curds"  were  formed  of  cal- 
cium soaps,  epithelium,  bacteria,  and  intestinal  secretions.  It 
was  shown,  furthermore,  that  Biedert's  methods  of  proving  the 

1  Folin  and  Denis:  Jour,  of  Biol.  Chem.,  1912,  xi,  87  and  subsequent 
papers 

2  Van  Slyke  and  Meyer:  Jour.  Biol.  Chem.,  1912,  xii,  399. 
'  London:  Zeitschr.  f.  Physiol.  Chem.,  1913,  Ixxxvii,  313. 

*  Hendrix  and  Sweet:  Jotir.  Biol.  Chem.,  1917,  xxxii,  299. 
'  Biedert:  Jahrb.  f.  Kinderh.,  1888,  xxviii,  21. 

•  Wegscheider:  Ueber  normale  Verdauung  bei  Sauglingen.  Innaug.  Diss. 
Strassburg,  1875;  cited  by  Blauberg:  Experimentelle  and  kritische  Studien 
Uber  Sauglingsfeces  bei  naturUche  u.  kimstlicher  Ernahrimg,  Berlin,  1897. 

'Uffelmann:  Deutsch.  Arch.  f.  klin.  Med.,  1881,  xxviii,  437. 
8  Escherich:  Jahrb.  fur  Kinderh.,  1888,  xxvii,  100. 
» Fr.  Miiller:  Zeitschr.  fiir  Biol.,  1884,  xx,  327. 


DIGESTION  OF  PROTEIN 


47 


presence  of  casein  ^  were  of  no  positive  value  since  nucleo-protein 
and  nucleo-albumen  gave  the  same  tests.  ^ 

Talbot '  showed  that  there  are  two  kinds  of  curds,  one  of  which 
is  large  and  tough  and  contains  a  high  percentage  of  protein,  and 
the  other  which  is  small  and  soft  and  contains  a  low  percentage  of 
nitrogen  and  a  high  percentage  of  fat.  The  former  are  tough, 
bean-like  masses  of  varying  size  and  shape,  weighing  from  ^  to 
13^  gm.,  the  color  varying  from  white  to  greenish-yellow  according 
to  how  much  they  are  stained  by  the  bile  and  intestinal  secretions. 
They  may  be  easily  separated  from  the  fecal  material  in  which 
they  are  imbedded  and  become  extremely  hard  when  treated  with 
10%  formaline  solution.  These  curds  are  the  ones  examined  by 
Biedert.  The  small,  soft  curds  are  either  flat,  white  flakes  (which 
look  like  undigested  particles  of  milk)  or  pinhead  elevations,  which 
are  stained  green  or  yellow  by  the  intestinal  secretions.  They 
are  always  associated  with  more  or  less  mucus  and  are  composed 
almost  entirely  of  fat  in  the  form  of  fatty  acids  or  soaps.  These 
curds  are  probably  the  ones  examined  by  Biedert's  opponents. 

Knopf ehnacher  *  and  Selter  ^  examined  the  tough  curds  chem- 
ically and  concluded  that  they  were  composed  of  casein. 

The  chemical  composition  of  casein  curds  is  as  follows: 

TABLE  12 


Fai  in  food 

% 

Curds 

Neutral 

fat.% 

of  dried 

stool 

Fatty 
acid.% 
of  dried 

stool 

Soaps. 
%of 
dried 
stool 

Avthor 

Nitro- 
gen. % 
of  dried 
stool 

Total 
fat.% 
of  dried 

stool 

Talbot* 

3.75 

3.50 
"Eiweissmilch" 

2.3 

1.8 
"Fat  free  milk" 

7.2 
9.8 
10.4 
10.6 
10.6 
12.0 

46.8 
28. 
27. 
22.3 
19.0 
8.4 

36.4 
21.4 

2.2 

4.6 
1.2 

0.8 

5.8 

Benjamin  * 

Courtney  • 

Talbot « 

5.6 
5.4 

*  Talbot:  Boston  Med.  and  Surg.  Jour.,  1908,  clviii,  905. 
'  Benjamin:  Zeitschr.  f.  Kinderh.,  1914,  x,  185. 

«  Courtney:  Am.  Jour.  Dis.  Children,  1912,  iii,  1. 

» Biedert:  Arch.  f.  Gynak.,  1907,  Ixxxi,  1. 

2  See  also  Southworth  and  Schloss:  Arch.  Pediatrics,  1909,  xxvi,  241. 

'  Talbot:  Boston  Med.  and  Surg.  Jour.,  1908,  clviii,  905;  and  ibid.,  Jan.  7, 1909. 

*  Knopf ebnacher:  Wien.  klin.  Wochenschr.,  1898,  1024;  ibid.,  1899,  1015; 
ibid.,  1899,  No.  52,  1038;  and  Jahrb.  f.  Kinderh.,  1900,  Iii,  545. 

» Selter:  Verhandl.  d.  Gesellsch.  f.  Kinderh.,  Stuttgart,  1906,  177. 


48  DIGESTION  OF  PROTEIN 

The  foregoing  table  gives  analyses  of  selected  curds  from  three 
investigators  and  shows  the  general  tendency  for  the  amount  of 
fat  in  the  curd  to  increase  with  the  amount  of  fat  in  the  milk. 
Conversely  the  amount  of  nitrogen  diminishes  as  the  fat  increases. 
This  seems  to  indicate  that  fat,  the  accidental  component  of  the 
curd,  dilutes  the  nitrogen. 

These  experiments  were  not  considered  conclusive  by  most 
pediatricians,  especially  those  of  the  schools  of  Czemy,  Finkelstein 
and  Heubner,  while  Biedert  and  many  American  schools  thought 
that  they  were  casein.  Wemstedt  ^  compared  under  the  micro- 
scope and  microchemically  the  tough  curds  found  in  the  stool 
with  those  found  in  the  stomach  and  concluded  that  they  were 
casein. 

Recently,  Talbot,  Bauer,  Uffenheimer  and  Takeno  ^  working  at 
approximately  the  same  time  with  different  methods,  showed 
by  the  precipitine  method,  by  anaphylaxis,  and  by  complement 
fixation  that  the  protein  in  tough  curds  was  cow  casein.  Liwschiz  ' 
repeated  this  work  and  found  that  casein  could  be  differentiated 
from  paracasein  by  complement  fixation. 

When  milk  curdles  in  the  infant's  stomach  it  entangles  a  large 
proportion  of  the  milk  fat  in  its  meshes  and  only  such  fat  as  Ues 
near  the  surface  of  the  curd  can  be  reached  by  the  digestive  juices. 
The  amount  of  fat  in  the  curd  depends  upon  the  amount  of  fat  in 
the  milk.^  Courtney  ^  did  not  find  any  great  variation  in  the 
percentage  of  fat  in  the  curds  examined  by  her.  This  is  what  would 
be  expected,  because  there  was  no  great  variation  in  the  percentage 
of  fat  in  the  food  of  the  babies  passing  the  curds.  She  went  fur- 
ther, however,  and  examined  the  stool  mass  surroimding  the  curds 
and  concluded  that  the  casein  curds  are  not  pathognomonic  of  any 
pathological  condition,  and  that  the  loss  of  food  occasioned  by 
their  formation  and  the  impairment  of  the  general  nutrition  re- 
sulting from  it  is  insignificant.  Finally,  that  in  attempting  to  cor- 
rect the  state  of  digestion  one  should  be  guided  by  the  general 
rules  of  infant  feeding,  paying  only  secondary  attention  to  the 
appearance  or  disappearance  of  curds  from  the  stools. 

Rowland  ^  believes  that  the  presence  of  casein  curds  in  the  stools 

'  Wemstedt:  Hygiea,  1907,  No.  9,  ref.  Munchen  Med.  Wochenschr.,  1907, 
2543. 

2  Talbot:  Arch.  Pediat.,  1910,  xxviii,  440;  Uffenheimer  and  Takeno:  Zeits. 
f.  Kinderh.,  1911,  ii,  32;  Bauer:  Monatschr.  f,  Kinderh.,  1911,  x,  239. 

*  Liwschiz :  Diss.  Munchen  1913,Zeitschr.  f .  Kinderh.,  Ref.,  1914,  viii,  345. 

*  Talbot:  loc.  cU. 

*  Courtney:  Am.  Jour.  Dis.  Children,  1912,  iii,  1. 
« Howland:  Am.  Jour.  Dis.  Children,  1913,  v.  390. 


DIGESTION  OF  PROTEIN  49 

is  of  "limited,  if  any,  pathological  importance,  but  rather  depends 
on  physical  conditions  in  the  gastrointestinal  tract."  Benjamin  ^ 
notes  that  casein  curds  appear  in  the  stools  of  healthy  as  well  as 
of  dyspeptic  infants  and  that  there  is  less  gain  in  weight  while  these 
curds  are  being  passed  than  when  they  are  absent.  There  is  no 
question,  however,  that  the  casein  curds  are  relatively  rare  in  in- 
fants' stools  and  that  their  presence  is  often  associated  with 
symptoms  of  indigestion. 

Ibrahim  ^  and  Brennemann  ^  observed  that  the  casein  curds 
appeared  in  the  stools  of  babies  fed  on  raw  milk  and  disappeared 
from  the  stools  when  the  milk  was  boiled.  They  both  suggest  boil- 
ing as  a  therapeutic  measure  for  preventing  the  formation  of  such 
cm"ds.  This  fact  explains  why  casein  curds  are  seldom  seen  in 
Germany  where  the  milk  is  almost  imiversally  boiled. 

Ibrahim  observed  that  the  curds  seem  to  come  more  easily  in 
babies  with  digestive  disturbances,  but  that  they  may  come  in 
otherwise  healthy  babies  who  are  fed  on  raw  milk.  He  saw  them 
in  a  two  and  one-half  year  old  child  which  had  a  typical  "digestion- 
insufficiency"  as  described  by  Heubner.^  The  most  recent  experi- 
ments of  Uff enheimer  ^  seem  to  indicate  that  casein  is  present  in 
the  stools  more  frequently  than  was  formerly  thought,  as  it  has 
been  found  in  the  salve-like  skimmed  milk  stools. 

Selter^  described  a  picture  of  "intoxication"  in  which  there 
is  an  excursion  of  temperature  from  37°  to  34"  (i.  e.,  subnormal), 
slow  pulse  and  superficial  respiration.  The  color  of  the  skin  is 
bluish-gray.  The  urine  contains  no  reducing  substance.  The 
stools  are  curdy  and  grayish-yellow,  with  a  cheesy  odor.  The 
urine  contains  a  kenotoxine,  which,  when  injected  into  mice, 
causes  a  condition  similar  to  that  described  in  the  babies.  The 
disease  is  cured  by  small  amounts  of  breast  milk,  or  by  carbohy- 
drates, and  is  attributed  to  the  proteins. 

MeUanby'^  beheves  that  a  substance  known  as  j8  imidozoly- 
ethylamine  is  accountable  for  the  symptoms  in  the  acute  diar- 
rheas of  infants.  This  substance  may  be  derived  from  amino-acid 
histidin  by  the  removal  of  COj  and  is  related  to  ptomaines. 

*  Benjamin:  Zeitschr.  f.  Kinderh.,  1914,  x,  185. 
'Ibrsjiim:  Monatschr.  f.  Kinderh.,  1911,  x,  55. 

*  Brennemann:  Am.  Jour.  Dig.  Children,  1911,  i,  341. 

*  Heubner:  Verhandl.  d.  Gesellsch.  f.  Kinderh.  in  Salzburg,  1909,  xxvi, 
169. 

^  Uffenheimer:  Sitzung  der  Miinchen  Gesellsch.  f,  Kinderh.,  1911;  Mtinchen 
med.  Wochensehr.,  1911,  876. 

«Selter:  Deutsch.  med.  Wochensehr.,  1908,  512. 
'  Quart.  Jour.  Med.,  1915-16,  ix,  164. 


50  DIGESTION  OF  PROTEIN 

Schloss  ^  found  that  in  "intestinal  intoxication"  there  was  often 
acidosis  and  an  increase  of  the  non-protein  nitrogen  and  urea  of  the 
blood.  Although  acidosis  plays  a  definite  part  in  the  symptoma- 
tology, and  the  symptoms  are  essentially  those  of  uremia,  he  con- 
cludes that  the  essential  cause  is  probably  some  unknown  toxic 
agent.  The  evidence  at  hand,  therefore,  strongly  suggests  that 
some  product  of  protein  decomposition  is  responsible  for  the  symp- 
toms present  in  "intoxication."  It  is  wise  to  bear  in  mind  in  this 
connection  that  "intestinal  intoxication"  is  not  a  disease  entity 
but  is  merely  the  term  given  for  a  group  of  clinical  symptoms. 
Monrad  ^  and  Morse  ^  do  not  believe  with  Finkelstein  and  his 
followers  that  casein  is  absolutely  harmless,  but  think  that  it 
can  cause  dyspepsia.  Holt  and  Levene  ^  found  that  large  quanti- 
ties of  casein  given  by  mouth  could  cause  a  rise  in  temperature. 
They  observed  a  rise  in  temperature  in  five  instances  that  con- 
tinued until  the  food  was  changed,  and  then  subsided  to  normal. 
Fever  occurred  only  when  their  "synthetic  food"  contained  six 
per  cent  of  casein.  There  was  a  retention  of  chlorides  for  three 
or  four  days  preceding  the  rise  in  temperature.  They  call  attention 
to  the  parallelism  between  this  fever  and  that  produced  by  Vaughan 
by  the  parenteral  injection  of  protein.  Their  food  contained  a 
large  amount  of  salts,  however,  and  it  is  possible  that  the  fever 
may  have  been  caused  by  them. 

ANAPHYLAXIS 

The  connection  between  anaphylaxis  and  the  disturbances 
caused  by  cow's  milk  has  always  been  a  field  for  speculation.  Ham- 
burger ^  beheved  that  foreign  protein  ("artfremdes  Eiweiss")  was 
"an  irritant  to  the  especially  sensitive  cells  of  the  infant's  ali- 
mentary tract  and  that  the  necessity  of  breaking  down  the  pro- 
tein molecule  to  such  simple  substances  that  they  could  not  be 
injurious  after  absorption  threw  an  added  burden  on  the  digestion 
and  one  which  was  unnecessary  with  milk  of  the  same  species." 
Howland  ^  has  brought  forward  some  evidence  against  this  theory. 
Recent  investigations,  however,  have  added  positive  evidence. 
Moro  and  Bauer  ^  found  precipitines  in  the  blood  of  marantic 

» Schloss:  Am.  Jour.  Dis.  Ch.,  1918,  xv,  165. 

2  Monrad:  Monatsschr.  f.  Kinderh.,  1911,  x,  244. 

'  Morse:  New  York  Med.  Jour.,  1913,  xcvii,  477. 

*  Holt  and  Levene:  Med.  Klin.,  1913,  ix,  258. 

*  Hamburger:  quoted  by  Howland, — Am.  Jour.  Dis.  Children,  1913,  v.  390. 

*  Howland:  Am.  Jour.  Dis.  Children,  1913,  v.  390. 

'  Moro  and  Bauer:  quoted  by  Howland, — ^Am.  Jour.  Dis.  Children,  1913, 
V.  390. 


DIGESTION  OF  PROTEIN  51 

infants  in  a  few  instances.  There  is  not  much  doubt  that  during 
the  first  weeks  of  Ufe  a  foreign  protein  can  pass  through  the  in- 
testinal wall.  Schloss  ^  and  Berger  ^  have  given  indirect,  but  sug- 
gestive evidence  by  differential  counts  of  the  blood,  that  when  a 
foreign  protein  is  introduced  for  the  first  time  into  the  gastro- 
intestinal canal  of  infants,  there  is  a  similar  reaction  in  the  body 
to  that  obtained  in  active  sensitization  and  immunity  of  the  body. 
These  two  pieces  of  work  suggest  that  the  sequence  of  sensitiza- 
tion and  immunity  takes  place  when  any  foreign  protein  is  intro- 
duced into  the  intestinal  canal.  Lust  ^  fed  different  forms  of  for- 
eign protein  to  children  with  digestive  disturbances  and  found  by 
the  precipitine  reaction  that  egg  albumen  passed  through  the  in- 
testinal wall  in  nine  of  sixteen  cases  of  acute  and  chronic  nutritional 
disturbances,  while  ox  serum  passed  through  in  only  one  of  seven- 
teen cases.  Hahn  ^  found  that  in  five  out  of  twenty-three  infants 
with  acute  nutritional  disturbances  antitoxin  passed  from  the  in- 
testine into  the  blood.  ModigUani  and  Benini  ^  found  by  means 
of  the  precipitine  reaction  that  the  blood  of  infants  fed  on  cow's 
milk  showing  symptoms  of  gastrointestinal  disturbances,  was  al- 
ways positive  for  cow  casein.  Sick  new-bom  babies  gave  a  positive 
reaction,  while  older  breast-fed  babies  were  negative  even  when 
they  were  given  a  httle  cow's  milk  during  an  acute  intestinal 
disturbance.  No  healthy  infants  gave  positive  reactions.  These 
findings  have  been  recently  confirmed  in  a  carefully  controlled 
piece  of  work  by  Schloss  and  Worthen.®  Vaughan  ^  calls  attention 
to  the  fact  that  peptone  and  other  products  of  decomposition  of 
protein  may  cause  symptoms  of  disease  and  that  "sensitization 
may  result  from  the  absorption  of  undigested  or  partially  digested 
proteins  from  the  alimentary  tract." 

Differences  in  the  Absorption  of  Human  and  Cow^s  Milk  Ni- 
trogen.— In  most  instances  less  nitrogen  is  taken  in  the  food  of 
naturally  fed  babies  than  in  that  of  artificially-fed  ones,  but  when 
approximately  the  same  amounts  of  each  are  ingested  there  is  less 
fecal  nitrogen  in  the  artificially-fed  babies  than  in  those  fed  natu- 

*  Schloss:  Paper  read  at  the  Am.  Assoc,  for  the  Study  and  Adv.  of  Clinical 
Investigation,  May  11,  1914. 

*  Berger:  Paper  read  at  the  Thirty-fifth  meeting  of  the  New  England  Pedia- 
tric Society,  held  January  29,  1915. 

»  Lust:  Jahrb.  f.  Kinderh.,  1913,  Ixxvii,  383. 
<Hahn:  Jahrb.  f.  Kinderh.,  1913,  Ixxvii,  405. 

'  ModigUani  and  Benini:  PolicUnico,  Rome,  Dec.  med.  Section,  1914,  No. 
12,  533. 
'Schloss  and  Worthen:  Am.  Jour.  Dis.  Ch..  1916,  xi,  342. 
^  Vaughan:  Jour.  Am.  Med.  Assoc,  1913,  bd,  1761. 


52  DIGESTION  OF  PROTEIN 

rally.^  The  nitrogen  in  the  feces  of  both  naturally  and  artificially- 
fed  babies  increases,  other  things  being  equal,  with  an  increase  of 
nitrogen  in  the  food.  There  may,  however,  be  considerable  varia- 
tions in  the  nitrogen  excreted  by  the  same  child  on  the  same  food 
if  the  observation  is  continued  over  a  long  period  of  time,  as  is 
shown  by  the  work  of  Cronheim  and  Miiller.^ 

Starvation  stools. — Experiments  on  animals  and  man  have 
shown  that  during  starvation  there  are  only  small  amounts  of  ni- 
trogen in  the  feces,  that  when  a  nitrogen-free  food  is  given  there  is 
considerable  increase  in  the  fecal  nitrogen  ^  and  that  there  may 
be  more  nitrogen  in  the  stools  on  a  nitrogen-free  food  than  on  one 
containing  a  large  amount  of  nitrogen.  It  may  be  assumed,  there- 
fore, that  the  animal  albumins  are  probably  completely  or  al- 
most entirely  absorbed  in  health.  It  is  evident  also  that  the  ni- 
trogen in  the  feces  comes  principally  from  the  intestinal  secretions 
and  the  intestinal  bacteria.  Keller  ^  found  that  a  baby  excreted 
0.74  gm.  nitrogen  per  day  in  one  experiment  and  0.097  gm.  in 
another,  while  undergoing  starvation. 

It  would  be  expected  that  when  the  amount  of  food  is  in- 
creased there  would  be  an  increased  flow  of  digestive  juices,  but 
figures  do  not  bear  out  this  assumption.  Vegetable  nitrogen 
is  digested  and  absorbed  with  greater  difiiculty  than  animal 
nitrogen.  Wohlgemuth  ^  found  that  he  could  cause  an  increased 
flow  of  pancreatic  juices  in  a  man  with  a  pancreatic  fistula 
by  feeding  carbohydrates  and  that  protein  caused  a  less  profuse 
flow. 

Compositioii  of  Nitrogenous  Bodies  in  Stools. — It  has  already 
been  shown  that  tough  curds  are  formed  from  undigested  casein. 
A  large  part  of  the  remaining  fecal  material  is  due  to  the  bodies 
of  bacteria.  The  chemical  composition  of  the  nitrogenous  com- 
ponents of  the  stools  is  as  follows:^ 

Proteins  and  amino  acids 50-70% 

Free  amino  acids 2 . 4-24% 

Ammonia 3.0-37%  ^ 

*See  Tables  in  Keller:  Phosphor,  und  Stickstoff  im  Sauglingsorganismus. 
Arch.  f.  Kinderh.,  1900,  xxix,  1;  and  Orgler:  Ueber  Harnsaureansscheidung 
im  Sauglingsalter.    Jahrb.  f.  Kinderh.,  1908,  Ixvii,  383. 

2  Cronheim  and  Miiller:  Biochem.  Zeitschr.,  1908,  ix,  76. 

'  Rubner:  Zeitschr.  f.  Biol.,  1879,  xv,  115,  and  others. 

♦Keller:  Arch.  f.  Kinderh.,  1900,  xxix,  1. 

*  Wohlgemuth:  Berl.  klin.  Wochenschr.,  1907,  47. 

*  Van  Slyke,  Courtney  and  Fales:  Am.  Jour.  Dis.  Ch.,  1915,  ix,  533. 
7  Gamble:  Am.  Jour.  Dis.  Ch.,  ix,  519. 


METABOLISM  OF  PROTEIN  53 

THE   METABOLISM   OF   PROTEIN 

Schlossmann  and  Murschhauser  *  investigated  the  fasting  me- 
tabohsm  of  infants.  Their  paper  should  be  consulted  in  the  origi- 
nal for  the  literature  and  the  details  of  the  investigations.  They 
found  that  the  nitrogen  excretion  in  the  urine  during  fasting  de- 
pended upon  the  quaUty  of  the  food  ingested  before  fasting  was 
commenced  and  that  the  greater  the  protein  (nitrogen)  content 
of  the  food,  the  greater  was  the  excretion  of  nitrogen.  For  ex- 
ample, Baby  14: — 

TABLE  13 

Nitrogen  content  of  urine  per  Nitrogen  content  of  urine  per 

hour,  per  kilogram  hour  per  kilogram 

Grams  Grams 

Feeding  with  human  milk 0.00363  Modified  cow's  milk 0.0119 

On  first  day  of  fast 0.00513  First  day's  fast 0.0160 

On  second  day  of  fast 0.00686  Second  day's  fast 0.0151 

On  third  day  of  fast 0.01083  Food  again  given 0.0080 

On  first  day  after  fast 0.0068 

On  second  day  after  fast 0.0042 

When  human  milk  had  been  used  less  body  protein  was  broken 
down  during  starvation  than  when  modified  cow's  milk  was  used. 
After  eighteen  hours  of  fasting  the  nitrogen  in  the  urine  represents 
the  products  of  the  katabolism  of  the  body  protein.  The  acetone 
bodies  increase  in  the  urine  during  fasting,  and  the  evidence  points 
to  the  absence  of  carbohydrate  in  the  food  as  the  cause. 

When  the  amount  of  protein  in  the  food  is  increased  there  is 
increased  retention  of  nitrogen.^  Babies,  unlike  adults,  are  able 
to  retain  nitrogen  even  when  they  are  not  receiving  the  required 
number  of  food  calories.  They  may  continue  to  do  so  even  imder 
the  most  discouraging  circumstances. 

In  adults  when  the  total  carbohydrate  of  the  food  is  replaced  by 
fat  of  an  equal  caloric  value  there  is  a  considerable  albumin  def- 
icit.' If  only  a  part  of  the  carbohydrate  is  replaced  by  fat,  the 
body  will  eventually  return  to  a  nitrogenous  equilibrium.  Orgler 
beheves  that  in  normal  babies,  however,  the  amount  of  fat  in  the 
food  influences  the  nitrogen  metabolism  to  only  a  sUght  degree. 
Increasing  the  fat  in  the  food  of  babies  that  do  not  digest  fat  well 
may,  on  the  other  hand,  result  in  a  negative  nitrogen  balance. 
It  is  not  known  whether  the  action  of  the  fat  of  human  milk  and 

*  Schlossmann  and  Murschhauser:  Biochem.  Zeitschr.,  1913,  Ivi,  355. 

*  Meyer,  L.  F.:  Biochem.  Zeitschr.,  1908,  xii,  422. 

'  Landergreen:  Skandin.  Arch.  f.  Physiol.,  1903,  xiv,  112. 


54  METABOLISM  OF  PROTEIN 

of  cow's  milk  is  the  same  or  not.  In  Courtney's  cases  ^  the  nitro- 
gen retention  was  higher  in  those  babies  which  showed  a  very- 
considerable  gain  in  weight  in  the  course  of  the  experiment  and 
were,  therefore,  in  the  stage  of  reconvalescence.  Fat  does  not 
seem  to  have  the  property  of  sparing  protein. 

Carbohydrates,  on  the  other  hand,  have  a  marked  property  of 
sparing  nitrogen.^  Cane  and  milk  sugar  have  the  same  action 
as  malt  sugar.  When  they  are  added  to  the  food  there  is  usually 
an  increase  in  the  nitrogen  retention.  When  carbohydrates  are 
given  in  excess,  they  cause  increased  peristalsis,  frequent  stools 
and  a  considerable  loss  of  nitrogen  from  the  body.^-  ^ 

The  growing  body  requires  protein  from  which  to  build  up  the 
body  tissues,  muscles,  etc.,  while  carbohydrates  and  fats  are  used 
as  fuel.  It  is  obvious,  therefore,  that  more  protein  or  nitrogen 
must  be  ingested  than  is  excreted  in  order  that  the  needs  of  the 
growing  tissues  may  be  suppUed.  The  osseous  system,  in  the  same 
way,  requires  mineral  salts  for  its  growth,  and  more  salts  must  be 
ingested  in  the  food  than  are  lost  in  the  excreta.  These  salts  which 
are  retained  in  the  body  are  used  to  build  up  new  bone.  When  the 
baby  is  gaining  weight  and  strength,  there  is  a  retention  of  both 
nitrogen  and  salts  and  when  the  baby  is  not  gaining,  there  may  be 
a  loss  of  both  of  these  bodies.  When  one  is  retained  in  the  body  the 
other  is  apt  to  be  retained,  and  vice  versa,  as  shown  by  Orgler's 
Baby  No.  9.^ 

The  metabolism  of  breast-fed  babies  can  be  compared  more 
easily  than  of  that  bottle-fed  babies  because  the  food,  i.  e.,  breast 
milk,  is  essentially  the  same  in  all  cases,  while  that  of  artificially- 
fed  babies  differs  a  great  deal.  Orgler  found  that  in  general  there 
is  more  nitrogen  retained  per  kilogram  of  body  weight  in  young 
babies  than  in  older  babies;  that  is,  the  retention  decreases  as 
the  baby  grows  older. 

Both  the  retention  and  the  utilization  of  nitrogen  must  be  taken 
into  consideration  when  the  various  cases  in  literature  are  com- 
pared. Utihzation  represents  the  amount  retained  as  compared 
with  the  amount  in  the  food.  The  following  table  taken  from 
Schwarz  gives  an  idea  of  utilization : 

1  CJourtney:  Am.  Jour.  Dis.  Chadren,  1911,  i,  321. 

*  Keller:  Maltsuppe,  eine  Nahrung  fiir  magendarmkrauke  Sauglings.  Jena, 
1903. 

» Orgler:  Jahrb.  f.  Kinderh.,  1908,  Ixvii,  383. 

*  Talbot  and  Hill:  Am.  Jour.  Dis.  ChUdren,  1914,  viii,  218. 

»  Meyer,  L.  F. :  Ergebniss  d.  inn.  Med.  und  Kinderh.,  1908,  i,  317. 


METABOLISM  OF  PROTEIN  66 

TABLE   14 


Age 

Up  to  14  days 

2-S  months 

6  months 

Retention 

0.351 

78.3% 

0.153 
40.8% 

0.048 

Utilization 

23.1% 

The  foregoing  table  shows  that  the  younger  the  baby  is,  the 
greater  is  the  retention  and  utilization  of  nitrogen.  This  cor- 
responds with  clinical  observations  of  growth,  for  the  very  young 
baby  grows  very  rapidly  and,  therefore,  retains  and  reuses  more 
nitrogen  in  building  up  new  body  tissues  than  the  older  baby 
which  does  not  increase  so  rapidly  in  size.  Under  certain  con- 
ditions of  under-nourishment,  an  increase  in  the  amount  of  nitro- 
gen in  the  food  results  in  an  increased  retention  of  nitrogen  and 
improvement  in  the  general  condition  of  the  baby. 

Baby  F.  W.  L.  studied  by  Talbot  and  Gamble  ^  gained  weight 
rapidly  and  retained  increasing  amounts  of  nitrogen  as  the  ni- 
trogen in  the  food  was  increased  until  period  5,  when  the  greatest 
amount  of  protein  was  given  in  the  food,  and  as  a  result  casein 
curds  appeared  in  the  feces,  and  less  nitrogen  was  retained. 
Coincidently  symptoms  of  indigestion  appeared  and  the  baby 
refused  to  take  all  its  food.  These  figures  are  the  only  ones 
which  show  that  casein  curds  in  the  stools  represent  an  increased 
excretion  of  nitrogen  from  the  body.  They  are  probably  the 
only  true  record  of  the  metabolism  during  protein  indigestion. 

In  other  conditions  an  increase  of  the  food  nitrogen  causes  greater 
retention  but  not  necessarily  a  gain  in  weight.  There  is  no  ex- 
planation of  why  this  increase  in  the  retention  of  nitrogen  does  not 
necessarily  benefit  the  baby.  Sick  infants  cannot  retain  as  much 
nitrogen  as  well  babies  of  the  same  age.  Fife  and  Veeder  ^  found 
that  two  cases  of  infantile  atrophy  had  a  greater  retention  of  ni- 
trogen than  normal  babies  of  the  "same  age  and  weight."  The 
question  may  be  raised,  however,  as  to  whether  the  babies  examined 
could  have  been  atrophic  if  they  were  of  the  same  weight  as  nor- 
mal babies  of  the  same  age.  When  the  amount  of  carbohydrate  in 
the  food  was  increased  there  was  increased  retention  of  nitrogen 
but  the  nitrogen  retention  was  not  influenced  by  the  amount  of 
fat  in  the  food. 

Czemy  and  Steinitz  '  have  collected  the  figures  of  the  nitrogen 

» Talbot  and  Gamble:  Am.  Jour.  Dis.  Ch.,  1916,  xii,  333. 
*Fife  and  Veeder:  Am.  Jour.  Dis.  Children,  1911,  ii,  19. 
'  Czemy  and  Steinitz:  Stoffwechselpathologie  des  Kindes,  Noorden's  Hand- 
buch  d.  Path.  d.  Stoffwechsels,  II,  391. 


56  METABOLISM  OF  PROTEIN 

metabolism  of  infants  with  disturbances  of  digestion  and  found 
that  the  absorption  was  approximately  normal  except  during 
diarrhea.  Although  the  evidence  all  seems  to  show  that  there  is  a 
retention  of  nitrogen  in  practically  all  instances,  yet  this  evidence 
is  not  suJ05cient  to  warrant  its  acceptance  without  reserve.  Gam- 
ble/ has  shown  that  in  alkaline  stools  twenty  per  cent  of  the  ni- 
trogen can  be  lost  in  the  form  of  ammonia  during  the  process  of 
drying.  This  loss  of  nitrogen  has  not  been  taken  into  considera- 
tion in  the  metabolism  experiments  of  other  writers  and  might 
be  sufficient  to  result  in  a  negative  balance  of  nitrogen  in  some 
of  the  instances  in  w^hich  the  balance  has  been  reported 
positive. 

Protein  Needs  of  Infants. — The  increasing  tendency  to  feed 
infants  on  dilutions  of  whole  milk  also  necessitates  giving  larger 
amounts  of  protein  in  the  food  than  is  required  by  the  body  for 
growth.  During  metabolism  the  very  process  of  digestion  uses 
up  energy.  It  has  been  shown  repeatedly  that  the  increase  of 
metabolism  due  to  fat  or  carbohydrate  is  very  slight,  but  that 
the  increase  incident  to  protein  hydrolysis  may  be  30%.^  It, 
therefore,  seems  uneconomical  to  burden  the  digestion  any  more 
than  is  necessary  with  the  food  component  which  uses  up  so  much 
energy  in  preparing  itself  for  use.  The  figure  commonly  given 
as  the  caloric  needs  of  infants  is  2  grams  of  protein  per  kilogram 
of  body  weight.  Hoobler  ^  considers  that  the  protein  needs  will 
be  supphed  for  growth  if  7%  of  the  food  calories  are  in  the 
form  of  protein.'  This  figure  is  probably  a  Httle  too  low  for  the 
average  infant.  It  has  also  the  additional  disadvantage  that 
it  requires  a  relatively  high  amount  of  fat  and  sugar  to  supply 
enough  calories.  It  is,  therefore,  safer  to  figure  that  2  grams  of 
protein  per  kilogram  of  body  weight  is  the  lowest  amount  of 
protein  on  which  an  infant  can  thrive,  that  it  is  wise  to  keep  the 
amount  of  protein  relatively  low,  but  never  lower  than  this  point, 
and  that  larger  amounts  may  be  given,  if  the  digestion  is  such 
that  sufficient  calories  cannot  be  supplied  in  fat  and  carbo- 
hydrate. 

Vitamines. — Although  the  food  may  contain  enough  calories  and 
protein  to  supply  the  requirements  of  an  infant,  it  may  not  con- 
tain the  proper  "vitamines"  necessary  for  growth.  These  are  of 
two  types  and  are  described  by  McCollum  as  fat  soluble  A  and 
water  soluble  B.    Most  of  the  knowledge  on  this  subject  is  foimded 

*  Gamble:  Am.  Jour.  Dis.  of  Children,  1915,  ix,  519. 

«  Lusk:  Sc.  of  Nutrition:  Phila.  and  London,  1917,  3rd  Ed.,  p.  238. 

'  Hoobler:  Am.  Jour.  Dis.  Ch.,  1915,  x,  153. 


METABOLISM  OF  PROTEIN  57 

on  animal  feeding  experiments  ^  and  need  not  necessarily  apply 
to  the  human  infant,  but  in  all  probability  the  fundamental 
principles  will  be  the  same  in  either  case;  "There  is  greater 
value  in  lactalbumen  in  promoting  growth  than  in  casein  be- 
cause the  amino  acids  are  arranged  in  more  suitable  proportions. 
The  protein  of  whey  appears  to  be  as  perfect  a  material  for  use 
in  the  service  of  growth  as  any  protein  known."  ^  The  amino 
acids  which  play  an  essential  r61e  in  growth  are  lysin,  cystin,  tryp- 
tophan, and  glycocoll,  while  others  may  have  a  minor  part.  Their 
arrangement  and  relation  to  one  another  must  fall  within  definite 
limits  for  the  optimum  results. 

*  See  Lusk:  Science  of  Nutrition,  3rd  Ed.,  1917,  Phila.  and  London,  pp.  368 
et  seq. 


CHAPTER  V 
THE  METABOLISM  OF  THE  MINERAL  SALTS 

The  metabolism  of  the  mmeral  salts  was  first  investigated  by 
Liebig  ^  in  1840.  Very  little  information  of  value  in  relation  to 
the  problems  of  infant  feeding  and  metaboUsm  has  been  added 
since  then,  however,  mitil  recent  years.  Even  such  information 
as  we  now  have  is  being  continually  modified  or  disproved  by 
chemists,  who  find  that  the  methods  which  were  employed  in  ob- 
taining the  figures  gave  erroneous  results.  Summaries  of  the  pres- 
ent knowledge  of  the  metabolism  of  the  mineral  salts  are  given 
by  Albu-Neuberg,^  L.  F.  Meyer,^  Hoobler,^  and  Tobler  and  Bes- 
sau.^ 

The  body  of  the  new-bom  infant  is  relatively  richer  in  water 
and  fat  and  poorer  in  nitrogen  and  ash  than  the  body  of  the  adult. 
The  body  of  the  fetus  contains  a  very  large  proportion  of  water, 
the  proportion  diminishing  as  the  fetus  grows  older.  The  com- 
position of  the  ash  of  the  new-bom  infant  is  according  to  Soldner  ® 
as  follows: 

In  one  hundred  parts  of  the  new-born  infant  there  is  K2O, 
7.06;  NaaO,  7.67;  CaO,  38.08;  MgO,  1.43;  P2O3,  0.11;  F2O3,  0.83; 
MnsO*,  0.03;  S2O5,  37.66;  Soa,  2.02;  CI,  6.61;  SiOz,  0.06;  C02, 
0.53. 

Human  milk  contains,  with  the  exception  of  iron,  much  less 
of  the  mineral  salts  than  cow's  milk.  More  of  the  salts  in  human 
milk  are  in  organic  combination  than  in  cow's  milk  and  for  that 
reason  are  supposed  to  be  utiUzed  more  easily.  Soldner^  found 
that  the  sodium,  potassium,  and  chlorine  content  of  human  milk 
decreased  as  lactation  progressed,  while  the  bone-forming  con- 

*  Liebig:  Chemie  in  ihre  anwendungs  fiir  Agrikultur  und  Phys,,  1876. 

*  Albu-Neubei^:  Mineralstoffwechsel,  Berlin,  1906. 

»  Meyer,  L.  F.:  Ergebnisse  d.  inn.  Med.  u.  Kinderh.,  1908,  i,  317. 
*Hoobler:  Am.  Jour.  Dis.  Children,  1911,  ii,  107. 

*  Tobler  and  Bessau:  Allgemeine  Pathologische  Physiologie  der  Emahning 
und  des  Stoffwechsels  im  Kindesalter,  Wiesbaden. 

"  Soldner:  quoted  in  Pfaundler  and  Schlossmann:  The  Diseases  of  Children, 
Phila.  and  London,  1908,  i,  364. 
^  Soldner:  loc.  cU, 

58 


METABOLISM  OF  SALTS  69 

stituents,  calcium,  magnesium  and  phosphorus,  remained  fairly 
constant. 

The  mineral  salts  play  a  very  complicated  part  in  digestion, 
because  they  are  not  only  absorbed  by  the  intestines,  but  also 
may  be  re-excreted  into  the  digestive  canal.  There  are  also  com- 
plicated reactions  which  take  place  between  the  organic  and  in- 
organic food  components. 

The  digestive  juices  contain  salts.  Bile  contains  from  ^  to 
1%  of  ash,  which  is  especially  rich  in  sodium  and  chlorides.^  It 
also  contains  smaller  amounts  of  potassium,  calcium,  and  mag- 
nesium in  combination  with  phosphoric  acid.  The  pancreatic 
juices  contain  J^%  of  ash,  the  greater  part  of  which  is  in  the  form 
of  sodium  carbonate.  The  intestinal  secretions  are  also  rich  in 
carbonates. 

Metabolism  of  Ash. — Cow's  milk  contains  much  more  ash  than 
human  milk,  and,  therefore,  much  more  salt  is  given  to  the  in- 
fant taking  an  artificial  food  prepared  with  cow's  milk  than  it 
requires.  The  breast-fed  infant  ^  absorbs  about  80%  of  the  ash  in 
the  food  and  retains  between  40%  and  50%  while  the  artificially- 
fed  infant  absorbs  from  43%  to  78%  and  retains  from  43%  ^  to 
none  at  all  or  may  even  loose  ash  from  the  body.^  Hoobler '  found, 
in  his  experiments,  that  the  retention  of  mineral  salts  as  compared 
with  the  retention  of  nitrogen  was  relatively  poor.  The  retention 
was  poorest  when  the  food  contained  but  little  fat,  was  better 
when  it  contained  a  medium  amount  of  fat,  and  was  best  when 
it  contained  a  large  amount  of  fat  (5.4%).  Talbot  and  Hill  ^ 
kept  the  fat  and  protein  in  the  food  approximately  the  same  in 
seven  periods,  and  found  that  when  the  carbohydrate  was  in- 
creased beyond  the  limit  of  tolerance  and  diarrhea  resulted  there 
was  a  loss  of  ash  from  the  body.  The  increased  excretion  of  ash 
was  through  the  feces.  A  careful  study  by  Holt  and  his  co-workers  ^ 
showed  that  in  loose  stools  as  much  as  84%  of  the  intake  may  be 
lost,  the  principal  loss  being  salts  other  than  calcium  phosphate. 
Chlorin,  potassium  and  sodium  are  normally  present  in  relatively 
small  amounts  in  normal  stools  but  in  loose  stools  they  are  ex- 
creted in  large  enough  amounts  to  result  in  a  loss  of  sodium  and 
potassium  from  the  body.^ 

Metabolism  of  Calcium. — ^The  metabolism  of  calcium  is  de- 

*Tobler:  loc.  cU. 

»  Blauberg:  Zeitschr.  f.  Biol.,  1900,  xl,  1. 

»  Hoobler:  Am.  Jour.  Dis.  Children,  1911,  ii,  107. 

*  Talbot  and  Hill:  Am.  Jour.  Dis.  Children,  1914,  viii,  218. 

*  Holt,  Courtney  and  Fales:  Am.  Jour.  Dis.  Ch.,  1915,  ix,  533. 


60 


METABOLISM  OF  SALTS 


scribed  in  detail  in  the  chapter  on  rickets.  For  that  reason  it  is 
unnecessary  to  speak  of  it  here  except  to  say  that  some  investiga^ 
tors  criticise  the  methods  which  were  used  to  quantitate  the 
amount  of  calcium  and  show  that  they  are  inaccurate. 

Metabolism  of  Iron. — ^The  amount  of  iron  in  both  cow's  milk 
and  human  milk  is  small  and  is  insuflScient  for  the  needs  of  the 
growing  infant.  Nature  has  deposited  enough  iron  in  the  liver  ^ 
of  the  new-born  infant,  however,  to  last  until  it  can  digest  foods 
which  contain  sufficient  amounts  of  iron.  The  iron  in  human 
milk  is  apparently  more  easily  retained  than  that  in  the  milk  of 
animals.  The  following  table  of  Krasnorgorski  ^  illustrates  this 
point. 

TABLE  15 

Iron  Metabolism  op  the  Same  Baby  in  two  Pemods 


Author 

Pood 

Iron  in 
food 

Feces 

Urine 

Ab- 
sorbed 
mg. 

Ab- 
sorbed 
% 

Re- 
tained 
mg. 

Re- 
tained 

% 

Krasnor- 
gorski 

Krasnor- 
gorski 

Human  milk 
Gioat's  milk 

7.05  mg. 
3.44   " 

0.84  mg. 
2.69    " 

0.55  mg. 
0.09    " 

6.21 
0.85 

88.09 
24.71 

5.66 
0.76 

80.28 
22.09 

Metabolism  of  Magnesium. — The  absorption  and  retention  of 
magnesium  are  higher  in  the  breast-fed  than  in  the  artificially- 
fed  infant.  Hoobler  '  found  that  when  an  infant  was  taking  an 
artificial  food  the  retention  was  better  when  there  was  a  low  per- 
centage of  fat  in  the  food  than  when  there  was  a  high  percentage 
of  fat. 

Metabolism  of  Phosphorus. — One  Hter  of  human  milk  contains 
from  0.31  to  0.45  gram  of  phosphorus  and  one  hter  of  cow's  milk 
about  1.81  grams.  Three-quarters  of  the  phosphorus  in  human 
milk  is  in  organic  combination,  while  only  one-quarter  of  the  phos- 
phorus in  cow's  milk  is  in  organic  combination;  41.5%  of  the 
total  phosphorus  in  human  milk  is  in  the  form  of  nucleon  phos- 
phorus and  only  6%  in  cow's  milk. 

According  to  Blauberg  ^  89.2%  of  the  phosphorus  in  human 
milk  and  53.2%  of  that  in  cow's  milk  is  absorbed.   Hoobler  ^  found 


»  Bunge:  Zeitschr.  f.  Physiol.  Chemie,  1889,  xiii,  399. 

»  Quoted  by  L.  F.  Meyer:  Ergeb.  d.  inn.  Med.  u.  Kinderh.,  1908,  i,  327. 

» Hoobler:  loc.  cit. 

'Blauberg:  see  Hoobler,  loc.  cit. 


METABOLISM  OF  SALTS  61 

that  more  was  absorbed  when  the  food  contained  a  high  per  cent, 
than  when  it  contained  a  low  per  cent,  of  fat.  Knox  and  Tracy  ^ 
confirmed  the  work  of  Keller  showing  that  the  bottle-fed  baby 
excretes  much  more  phosphorus  in  the  urine  than  the  breast-fed 
infant.  The  latter  excretes  very  Uttle  or  none.  According  to 
L.  F.  Meyer,  2  the  retention  of  phosphorus  is  less  in  the  artificially- 
fed  than  in  the  breast-fed  infant,  the  former  retaining  about  30% 
of  the  intake  and  the  latter  69.13%. 

Metabolism  of  Sodium  and  Potassium. — ^There  is  more  potas- 
sium than  sodium  in  milk.  Human  milk  contains  less  sodium  and 
potassium  than  cow's  milk.  The  absorption  of  these  salts  is  good 
for  both  milks.  The  retention  is  better  on  human  mUk  than  on 
cow's  milk,  being  67%  for  sodium  and  74%  for  potassium  on 
human  milk,  while  on  cow's  milk  it  is  15.27%  for  sodium  and 
16.12%  for  potassium.  Both  salts  are  eliminated  in  both  the 
urine  and  feces,  from  15%  to  25%  of  the  intake  being  eliminated 
in  the  feces.' 

Metabolism  of  Chlorides. — ^Very  Uttle  is  known  about  the  me- 
tabolism of  the  chlorides. 

Metabolism  of  Sulphur. — Hoobler  finds  that  the  sulphur  of  both 
human  and  cow's  milk  is  well  absorbed,  the  absorption  taking  place 
principally  in  the  small  intestine.  Sulphur  is  eliminated  almost 
entirely  through  the  urine,  but  a  small  part  is  eliminated  into  the 
large  intestine.  The  retention  of  sulphur  is  better  when  human 
milk  is  taken  than  when  cow's  milk  is  taken. 

The  Influence  of  the  Various  Food  Components  on  the 
Metabolism  of  the  Mineral  Salts. — There  are  very  few  in- 
vestigations which  throw  any  Ught  on  the  influence  of  the 
individual  food  components  on  the  metabolism  of  the  mineral 
salts. 

Howland  *  found  that  carbohydrates  increased  the  retention  of 
calcium. 

L.  F.  Meyer  found  that  the  addition  of  casein  to  the  food  di- 
minished the  absorption  of  all  the  mineral  salts. 

Steinitz  ^  Rothberg  ®  and  Birk  ^  found  that  as  the  fat  in  the 

*  Knox  and  Tracy:  Am.  Jour.  Dis.  Children,  1914,  vii,  409. 

*  Meyer,  L.  F.:  Ergeb.  d.  inn.  Med.  u.  Kinderh.,  1908,  i,  317. 

»  Hoobler:  Am.  Jour.  Dis.  Children,  1911,  ii,  107.    See  table  and  references. 

*  Howland  (not  yet  published).  BLead  before  the  Am.  Ped.  Soc'y,  Wash., 
1913. 

» Steinitz:  Monatsschr.  f.  Kinderh.,  1902-3,  i,  225;  Jahrb.  f.  Einderh.  1903, 
Ivii,  689. 

*  Rothberg:  Jahrb.  f.  Kinderh.,  1907  Ixvi,  69. 
"•  Birk:  Jahrb.  f.  Kinderh.,  1907,  bcvi,  300. 


62  METABOLISM  OF  SALTS 

food  was  increased  the  loss  of  mineral  salts  in  the  feces  was 
also  increased.  This  loss  was  especially  of  calcium  and  mag- 
nesium and  sometimes  resulted  in  a  negative  balance.  Court- 
ney ^  on  the  other  hand,  did  not  find  that  fat  had  any  marked 
influence  on  the  retention  of  ash  in  infants  with  chronic  in- 
digestion. 

L.  F.  Meyer  ^  found  that  infants  with  "Bilanzstorung"  lost 
from  34%  to  60%  of  the  ash  in  the  food  through  the  feces  as  com- 
pared with  from  20%  to  25%  in  normal  cases.  In  the  stage  of  in- 
toxication he  found  that  more  sodiimi,  potassium,  and  chloride 
were  lost  in  the  feces  but  that  there  could  still  be  a  retention  of 
calcium  and  phosphorus.  There  is  always  a  loss  of  ash  from  the 
body  ^  in  acute  diarrhea,  although  even  under  these  circumstances 
a  retention  of  calcium  is  possible.  The  reverse  is  apparently  true 
when  "soap  stools"  are  passed. 

Relation  of  (Edema  to  Salts. — (Edema  is  due  to  a  retention  of 
salts  in  the  body.  This  connection  between  the  two  is  shown  by 
the  analyses  of  Klose  ^  who  examined  post-mortem  the  bodies  of 
normal  and  oedematous  infants.  He  found  that  29%  of  the 
water  content  of  the  body  in  a  normal  infant  was  in  the  muscles 
and  21%  in  the  skin  and  subcutaneous  tissue,  while  in  infants 
with  oedema  there  was  slightly  less  fluid  in  the  muscles  and  much 
more  than  the  normal  amount  in  the  skin  and  subcutaneous  tis- 
sue. Apparently  there  is  much  less  subcutaneous  fat  in  oedema- 
tous infants  than  in  the  normal  but  in  its  place  there  is  an 
increase  in  the  sodium  chloride. 

Diarrhea. — -(See  page  33.)  During  many  cases  of  diarrhea  which 
are  not  of  the  ileocolitis  type,  Rowland  and  Marriott  ^  have  shown 
that  there  is  a  diminution  of  the  alkaU  reserve  in  the  blood  and  an 
acidosis  (see  chapter  on  Acidosis).  Judell®  finds  that  in  diarrhea 
the  ash  retention  is  diminished,  or  in  severe  grades  there  is  a 
negative  balance,  the  loss  being  due  especially  to  sodium  and 
potassium.  Holt^  and  his  co-workers  found  that  in  diarrhea 
there  is  relatively  a  much  greater  amoimt  of  chlorin,  sodium  and 
potassium  in  the  stool  than  of  calciimi  and  magnesium.  There  is 
two  and  a  half  times  as  much  fat  and  protein  in  diarrheal  stools 

^  Courtney:  Am.  Jour.  Dis.  Children,  1911,  i,  321. 
« Meyer,  L.  F.:  Jahrb.  f.  Kinderh.,  1910,  bm,  379. 
'  Tobler  and  Bessau:  loc.  cit. 

*  Kloae:  Jahrb.  f.  Kinderh.,  1914,  bmc,  154. 

'  Howland  and  Marriott:  Am.  Jour.  Dis.  Ch.,  1916,  ad,  309. 

•  Judell:  Zeitschr.  f.  Kinderh.,  1913,  viii,  235. 

^  Holt:  Courtney  and  Fales,  Am.  Jour.  Ch.,  1915,  ix,  213. 


METABOLISM  OF  SALTS  63 

as  there  is  in  normal  stools.    The  relation  of  excretion  to  intake 
is  as  follows: — 

Fat:  loss  in  normal  stools 12 . 4%  of  intake 

very  loose  stools 40.5%   "      " 

Protein:  loss  in  normal  stools 7.7%   "      " 

loose  stools 14.9%  "      " 

very  loose  stools 25.2%  "      " 

Ash:  loss  in  normal  stools 40.0%   "      " 

very  loose  stools 84.3%   "      " 


CHAPTER  VI 
THE  ENERGY  METABOLISM  OF  INFANTS 

The  earliest  investigation  of  the  gaseous  metabolism  of  infancy 
is  that  reported  by  J.  Forster,  of  Munich  in  1877.^  He  found 
with  the  large  Pettenkofer-Voit  respiration  chamber  that  the  in- 
fant produces  much  more  carbon  dioxid  per  unit  of  weight  than 
does  the  adult.  In  France  Richet,  Langlois,  Variot  and  Saint- 
Albin,  Bonnoit,  Variot  and  Lavaille  ^  and  G.  Weiss  published  a 
series  of  investigations  on  the  metabolism  of  new-born  infants 
and  atrophic  infants  between  the  years  1885  and  1912.  In  1898 
the  classical  monograph  of  Rubner  and  Heubner  ^  appeared. 
They  studied  the  average  daily  requirement  of  food  of  a  normal 
infant  and  in  the  following  year  ^  of  an  atrophic  infant.  They 
point  out  the  fact  that  in  human  beings  the  carbon  dioxid  excre- 
tion is  proportional  to  the  body  surface,  whatever  their  size. 

In  1908  the  first  of  a  series  of  investigations  by  Schlossmann  and 
Murschhauser  ^  appeared,  and  this,  with  subsequent  articles,  the 
last  of  which  was  published  in  1914  ^  have  added  much  to  our 
knowledge  of  the  metabolism  of  infancy.  These  authors  emphasize 
the  influence  of  muscular  activity  on  metabolism  and  they  studied 
the  basal  metabolism  (Grundumsatz)  during  complete  repose  for 
the  purpose  of  comparing  the  metabolism  in  health  and  disease. 
They  conclude  that  slight  changes  in  the  temperature  of  the  sur- 
rounding air  are  without  influence  on  the  metabolism.  Their  in- 
vestigations led  them  to  study  also  the  fasting  metabolism  in  order 
to  eliminate  the  influence  of  work  done  during  digestion. 

Other  investigators,  whose  names  should  be  mentioned,  are 
Mensi,  Poppi,  Scherer '  Babak,  and  Hasselbach,  Bahrdt,  Birk, 
Edelstein  and  Niemann. 

*  Forster:  Amtl.  Ber.  d.  50  Versammlung  deutsch.  Naturforscher  u.  Aerzte 
in  Miinchen,  Munich,  1877,  355. 

*  For  synopsis  of  literature  see  Benedict  and  Talbot:  Gaseous  Metabolism 
of  Infants,  Carnegie  Institution  of  Washington,  Pubhcation  201. 

*  Rubner  and  Heubner:  Zeitschr.  f.  Biol.,  1898,  xxxvi,  1. 

*  Rubner  and  Heubner:  Zeitschr.  f.  Biol.,  1899,  xxxviii,  315. 
'Schlossmann  and  Murschhauser:  Biochem.  Zeitschr.,  1908,  xiv,  385. 
•Schlossmann  and  Murschhauser:  Biochem.  Zeitschr.,  1914,  Iviii,  483. 
'See  Benedict  and  Talbot:  Am,  Jour.  Dis.  Children,  1914,  viii,  1. 

64 


ENERGY  METABOLISM  65 

In  America,  Carpenter  and  Murlin  ^  studied  the  energy  metab- 
olism of  pregnant  women  before  and  after  the  birth  of  the  child. 

Howland  ^  studied  the  direct  calorimetry  and  compared  it  with 
the  heat  calculated  from  the  carbon  dioxid  excretion  and  oxygen 
consumption.  He  found  that  the  heat-production  as  directly  meas- 
ured and  as  indirectly  computed  was  strikingly  close,  the  greatest 
difference  being  2%.  Benedict  and  Talbot  ^  reported  from 
the  Nutrition  Laboratory  of  the  Carnegie  Institution  of  Wash- 
ington in  1914,  the  results  of  three  years'  investigations  with  a 
respiratory  chamber  on  about  eighty  babies,  of  which  sixty-one 
were  reported  in  detail.  Murlin  and  Hoobler  ^  reported  the  results 
of  their  investigations  with  a  respiratory  chamber  on  a  few  in- 
fants in  1915. 

Methods  of  Computing  the  Energy  Metabolism. — There  are 
several  ways  of  computing  the  energy  metaboUsm  of  infants:  first, 
by  measuring  the  heat  lost  by  an  infant  in  a  calorimeter;  second, 
by  computing  the  heat  production  by  collecting  the  carbon  dioxid 
excreted  and  measuring  the  oxygen  consumed  by  an  infant  in  a 
respiratory  chamber.  Zuntz  ^  has  computed  the  calorific  value 
of  oxygen  with  different  respiratory  quotients  and  these  figures 
may  be  considered  today  as  the  best  data  we  have  for  the  com- 
putation of  the  energy  output  from  the  measurement  of  the 
gaseous  exchange.  Knowing  the  respiratory  quotient  the  calcula- 
tion of  the  calorific  value  of  carbon  dioxid  is  a  simple  one.  (Bene- 
dict and  Talbot,  Carnegie  Institution  of  Washington,  Publication 
201,  Table  fifteen,  page  twenty-nine,  gives  the  calorific  equiva- 
lents of  carbon  dioxid.) 

It  is,  therefore,  possible  to  determine  how  many  calories  are  used 
during  a  given  period  when  the  carbon  dioxid  and  the  respiratory 
quotient  are  known;  thirdly,  the  energy  metabolism  has  been  com- 
puted by  investigators  who  have  measured  the  fat,  carbohydrate 
and  protein  intake  and  the  loss  of  fat,  carbon  and  nitrogen  in  the 
excreta;  and  finally,  the  energy  metabolism  is  roughly  computed 
by  clinicians  who  know  the  approximate  or  theoretical  composi- 
tion of  the  elements  in  the  food.    The  last  method  is  of  Uttle  or  no 

^  Carp>enter  and  Murlin:  Arch.  Internal  Med.,  1911,  vii,  184. 

*  Trans.  Fifteenth  Internat.  Cong.  Hyg.  and  Demog.,  1911,  ii,  438. 

» Benedict  and  Talbot:  Carnegie  Institution  of  Washington,  Publication 
201;  and  Am.  Jour.  Dis.  Children,  1914,  viii,  1. 

*  Murlin  and  Hoobler:  Am.  Jour.  Dis.  Children,  1915,  ix,  81.  See  also 
Bailey  and  Murlin,  Am.  Jour,  of  Obstetrics  and  Dis.  of  Women  and  Children, 
1915,  Ijud,  526,  for  the  Metabolism  of  New-born  Babies. 

*  Zuntz,  quoted  by  Benedict  and  Talbot:  Carnegie  Publication  of  Washing- 
ton, No.  201,  1914. 


66  ENERGY  METABOLISM 

scientific  value  since  the  composition  of  the  food  varies  even  when 
the  greatest  precautions  are  taken  to  keep  it  uniform.  It  is  of 
value  only  to  the  clinician  in  his  practical  work  and  may  give  false 
information. 

Rowland,  working  in  Professor  Lusk's  Laboratory  at  Cornell 
University  Medical  School,  showed  in  a  very  brilliant  way  that 
the  output  of  heat  when  measured  directly  and  when  computed 
from  the  carbon  dioxid  and  oxygen,  coincided  very  closely.  The 
greatest  difference  was  two  per  cent.  Other  investigations,  in 
which  the  heat  was  computed  from  the  carbon  dioxid  and  oxygen, 
are,  therefore,  within  very  small  limits  of  error. 

The  Effect  of  Muscular  Exercise  on  Metabolism. — Schloss- 
mann appreciated  the  fact  that  muscular  exercise  caused  a  marked 
increase  in  the  heat  production  of  an  infant.  Rowland  found  a 
difference  of  17.6%  and  39%  in  the  heat  production  between 
periods  of  quite  sleep  and  active  struggling  and  crying,  while 
Murlin  and  Hoobler  found  that  hard  crying  may  increase  the 
metaboUsm  as  much  as  40%.  Benedict  and  Talbot  found  that  an 
increase  of  60%  was  common  and  that  there  could  be  an  increase 
of  100%  (as  in  the  case  D  Q  Dec.  22  ^)  from  quiet  sleep  to  active 
exercise.  It  is  obvious,  therefore,  that  a  comparison  of  the  metab- 
olism of  an  active  healthy  infant  with  that  of  a  quiet  sick  infant 
is  of  no  value,  because  in  one  the  effect  of  muscular  activity  is 
added  to  the  basal  metabolism  and  in  the  other  it  is  not.  The 
basal  metaboUsm,  that  is,  the  metabolism  during  complete  mus- 
cular repose,  should  be  always  used  when  health  and  disease  are 
compared. 

The  Effect  of  Fasting  on  the  Metabolism. — ^There  is  evidence 
which  seems  to  show  that  the  metabolism  of  infants  after  taking 
food  is  always  higher  than  it  is  in  the  same  infant  while  fasting.^ 
Rowland,^  in  conmienting  on  one  of  his  experiments  says:  "This 
experiment,  so  far  as  one  can  do  so,  brings  additional  proof  to  the 
view  that  insufficient  food  reduces  the  carbon  dioxid  excretion, 
but  that  after  eighteen  hours,  a  fasting  metabolism  is  not  reached 
with  infants,  as  shown  by  the  normal  heat  production  and  by  the 
respiratory  quotient  of  0.81."  Schlossmann  and  Murschhauser  ^ 
found  that  after  eighteen  hours  of  fasting  acetone  soon  appears 
in  the  urine  in  considerable  quantities.  The  question  can  be 
raised,  therefore,  whether  an  infant,  which  has  b'een  starved  more 

^  Benedict  and  Talbot:  Carnegie  Institution  of  Washington,  Pub.  201,  p.  97. 
*  Schlossmann  and  Murschhauser :  See  Murschhauser,  Boston  Med.  and 
Surg.  Jour.,  1914,  clxxi,  185. 

3  Howland:  Tr.  Fifteenth  Intemat.  Cong.  Hyg.  and  Demog.,  1912,  ii,  438. 


ENERGY  METABOLISM  67 

than  twenty-four  hours  and  whose  urine  contains  considerable 
quantities  of  acetone,  can  be  considered  normal.  Benedict  and 
Talbot  *  studied  the  f astiiig  metaboUsm  of  several  infants  at  periods 
from  three  to  twenty-four  hours  after  food  had  been  given.  They 
found  that  the  respiratory  quotient  was  markedly  lowered  after 
eighteen  hours  of  fasting.  The  figures  of  heat  production  obtained 
were  inconsistent,  because  it  was  almost  impossible  to  obtain  half 
hour  periods  for  study  in  which  the  fasting  infant  was  in  complete 
muscular  repose.  If  the  metabolism  is  lower  after  eighteen  or 
twenty-four  hours'  fast  than  it  is  directly  after  taking  food,  it  must 
be  only  slightly  diminished.  Further  investigations  must  be  car- 
ried on  to  decide  at  which  point  the  metaboUsm  of  a  fasting  infant 
changes  from  a  physiological  condition  into  a  pathological  condi- 
tion. For  this  reason  recent  investigations  have  been  confined 
almost  entirely  to  measuring  the  metabolism  directly  after  food 
has  been  given. 

Comparison  of  Body  Surface  and  Metabolism. — For  many 
years  writers  on  metaboUsm  have  been  wont  to  emphasize  the  sig- 
nificance of  the  relationship  supposed  to  exist  between  the  metab- 
olism and  the  body  surface  rather  than  that  between  the  metab- 
olism and  the  body  weight.  The  idea  that  there  is  an  intimate 
relationship  between  body  surface  and  heat  production  was  first 
brought  out  by  Bergmann  ^  in  1847.  The  theory  lay  dormant 
for  many  years,  but  was  finally  resuscitated  and  put  forth  in  a 
brilUant  and  highly  stimulating  manner  by  Rubner  ^  in  1883,  to- 
gether with  experimental  evidence.  Based  fundamentally  on  New- 
ton's law  of  cooling,  it  received  great  attention  from  practically  all 
workers  in  physiology.  The  startling  evidence  which  was  brought 
forward  to  demonstrate  that  the  heat  production  per  square 
meter  of  body  surface  was  about  1,000  calories  for  practically 
aU  species  of  animals  lent  further  support  to  this  hypothesis. 

The  researches  of  Benedict  and  Talbot,^  confirmed  by  Murlin 
and  Hoobler,^  show  that  such  conclusions  are  not  warranted  in 
infancy  since  the  relation  between  the  basal  metaboUsm  of  in- 
fants and  the  body  surface  is  not  uniform.^  The  following  chart 
iUustrates  this  point: 

*  Benedict  and  Talbot:  Carnegie  Institution  of  Wash.,  Pub.  201. 

'  Bergmann  and  Leuckart:  Anatomisch-physiol.  Uebersicht  des  Thierreichs, 
Stuttgart,  1852,  272;  Bergmann:  Warmeokonomie  der  Thiere,  Gottingen, 
1848,  9. 

» Rubner:  Ztschr.  f.  Biol.,  1883,  xix,  545. 

*  Benedict  and  Talbot:  Am.  Jour.  Dis.  Children,  1914,  viii,  1. 
'  MurUn  and  Hoobler:  Am.  Jour.  Dis.  Children,  1915,  ix,  81. 

•Lusk  and  others  consider  that  there  is  a  very  definite  relation  between 


68 


ENERGY  METABOLISM 


CHART  I  (Benedict  and  Talbot) » 

Chart  showing  actual  body  weight  of  infants  and  heat  production  per  square 
meter  of  body-surface  (Meeh  formula)  per  twenty-four  hours 

HEAT  PER  SQUARE  METER  (MEEH)  PER  24  HOURS 


9.0 


8.0 


6.0 


2.0 


HT 

EO* 

BS» 

EK 

EF 

BL 

• 

PW. 

AS 

RA 

NO* 

PS* 

EH 

• 

LL  • 

LRB 
DO, 

RE, 

MA      , 
EN 

BF 

JP 

• 
•  DM 

• 
JM 

UH 

fIC 

• 

FR 

• 

BD* 

ER« 

•  FD 
LB 

WP, 

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•  JS 
EL* 

TC 

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TK< 

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md" 

IR* 

OS 

j-'i."' 

L    AD 

• 

•EC 

LO 

• 

• 
JV 

8%    mAs. 

*c» 

•ehs 

ES 

;v,v. 

lOS. 

625   575   625   675   725   775   825   875   925   975   1025  1075  1125  J175  1225  1275  1325  1375. 

CALORIES 


This  chart  shows  that  the  basal  metabolism  per  square  meter 
of  body  surface  varies  over  100%,  when  new-born  infants,  viz., 
those  lying  to  the  left  on  the  hne  marked  675  calories  are 
included.  Benedict  and  Talbot  ^  conclude, — "that  our  evidence 
points  strongly  and  conclusively  to  the  fact  that  the  active 
mass  of  protoplasmic  tissue  determines  the  fundamental  metab- 
olism. The  absence  as  yet  of  a  direct  mathematical  measure  of 
the  proportion  of  active  protoplasmic  tissue  does  not,  we  believe, 
in  any  wise  affect  the  convincing  nature  of  our  evidence." 

The  total  basal  metabolism  of  an  infant  increases  with  its  age 
and  weight,  as  would  be  expected.  On  the  following  chart,  taken 
from  the  paper  by  Benedict  and  Talbot,^  the  normal  infants  are 
indicated  by  crosses  and  the  abnormal  infants,  including  those  that 
are  imder-weight,  are  indicated  by  dots.  A  hypothetical  curve 
has  been  constructed  for  the  normals  that  shows  the  tendency 
of  the  metaboUsm  to  increase  with  the  weights  of  the  infant.  In 
general,  those  infants  which  weigh  more  than  the  average  for  the 

the  metaboUsm  of  adults  and  their  body  surface.  There  is  a  much  closer 
agreement  between  the  figures  when  the  body  surface  is  measured  by  the 
Du  Bois  formula  which  is  the  most  accurate. 

*  Benedict  and  Talbot:  Am.  Jour.  Dis.  Children,  1914,  viii,  1. 


ENERGY  METABOLISM 


69 


age  lie  above  the  curve  while  those  which  weigh  less  than  the  aver- 
age fall  below  the  curve. 

CHART  II 

Chart  showing  the  actual  body  weight  of  infants  and  the  total  heat  produc- 
tion per  twenty-four  hours 

TOTAL  HEAT  PER  24  HOURS 


9.2 

MT 

'5 

^s 

&4 

7.6 

AR 

^ 

^ 

^^ 

^ 

•ek 

EFX 

V 

^ 

RL 

Xpw 

s 

x6  0 

AS 

^ 

i::' 

ND 

PS 

EM 

• 

g6.2 

s 

4.4 

8.6 

,^ 

LRB 

•MA 

•eh 

rK.BF 

•JP 

•« 

;^ 

FD* 

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•CH 

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EL 

AC* 

oc 

EHS. 

KR»    Jl 

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• 
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• 
jv  sVsi 

OS. 

2.0 

< 

\Vl  UOS 

255 


285 


315 


845 


185  165  195  225 
k  =  NORMAL  INFANTS 
•    =     ABNORMAL  INFANTS  INCLUDING  THOSE  UNDERWEIGHT 


875        406 


435 


The  comparison  of  the  basal  heat  production  per  kilogram  of 
body  weight  is  of  more  practical  interest  to  the  clinician. 

Chart  III  on  the  next  page  is  taken  from  the  paper  of  Benedict 
and  Talbot. 

In  general,  the  babies  weighing  the  average  for  the  age  and  in  all 
respects  normal  fall  between  the  hnes  marked  A  and  B  or,  roughly 
their  basal  metabolism  is  between  52  and  63  calories  per  kilogram 
of  body  weight.  The  normal  infants,  other  than  new-borns,  that 
have  a  great  deal  of  fat  on  their  bodies  in  proportion  to  their  muscu- 
lature, have  a  basal  metabolism  of  between  forty  and  a  little  more 
than  fifty  calories  per  kilogram  of  body  weight.  New-born  infants 
are  included  in  this  class.   Most  of  the  infants  that  are  under-weight 


70 


ENERGY  METABOLISM 


CHART  III 

Chart  showing  the  actual  body  weight  of  infants  and  the  heat  production 
per  kilogram  per  twenty-four  hours 

HEAT  PER  KILOGRAM  OF  BOOY-WEIQHT  PER  24  HOURS 
A  B 


9.0 


8.0 


:6.o 


15.0 


*R3 

HT 

EQ 

EK 

RL* 

E^» 

PW 

• 

•  NO 

•ps 

«C, 

•r* 

EM 

• 

AS 
MM  1 

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• 

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er 

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GO     A 


have  a  basal  metabolism  of  more  than  sixty-five  calories  per  kilo- 
gram of  body  weight  and,  in  general,  the  more  they  are  under- 
weight, the  greater  is  the  basal  metabolism.  This  chart  shows 
that  the  basal  metabolism  per  kilogram  of  body  weight  may 
vary  100%  in  different  infants.  There  are  some  infants  that 
are  under-weight,  whose  vital  functions  are  so  depressed 
that  their  metabolism  instead  of  being  greater  than  the  aver- 
age per  kilogram  of  body  weight,  is  less  than  the  average. 
This  is  especially  true  of  infants  with  subnormal  temperatures, 
and  may  explain  why  some  infants  who  have  been  very  sick  and 
as  a  result  are  weak,  gain  weight  on  surprisingly  few  calories. 

The  Respiratory  Quotient. — The  respiratory  quotient  is  the 
ratio  between  the  volume  of  carbon  dioxid  expired  and  the  volume 


ENERGY  METABOLISM  71 

of  oxygen  inspired  during  the  same  time,  viz., — '  =  R.  Q. 

When  carbohydrates  are  burned  the  respiratory  quotient  is  unity, 
that  is,  for  every  hundred  volumes  of  carbon  dioxid  excreted  a 
hundred  volumes  of  oxygen  are  absorbed.  (The  respiratory  quo- 
tient for  carbohydrates  is  1.00.)  The  respiratory  quotient  for  fat 
is  0.713  and  for  protein  0.801.  The  respiratory  quotient,  when 
carefully  determined,  throws  considerable  light  on  the  character 
of  the  materials  burned  in  the  body. 

Caloric  Values. — Rubner's  "standard  values"  have  been 
widely  used  throughout  the  world  in  determining  the  average  fuel 
value  of  a  mixed  diet.    They  are: 

1  gram  of  protein 4.1  calories  (large) 

1  gram  of  fat 9.3  calories  (large) 

1  gram  of  carbohydrate 4.1  calories  (large) 

The  heats  of  combustion  of  the  carbohydrates  are  as  follows : 

Stohmann  ^  Emery  and  Benedict  * 

Dextrose 3.692  3.739 

Lactose 3.877  3.737 

Saccharose 3.959  3.957 

Starch 4.116 

Since  the  carbohydrates  used  in  infant  feeding  are  usually  sugars 
rather  than  starch,  the  caloric  value  of  the  carbohydrate  would 
be  more  accurate  if  a  lower  factor  were  used,  for  instance,  3.7  for 
lactose. 

Computed  Metabolism.^ — The  energy  quotient  is  the  term 
appUed  by  Heubner  ^  to  the  number  of  large  calories  per  kilogram 
of  body  weight  per  day  that  are  necessary  for  growth.  The  metab- 
olism of  a  large  number  of  infants  has  been  computed  when  the 
amount  of  fat,  carbohydrate,  or  protein  in  the  food  was  known, 
or  in  which  averages  of  the  various  analyses  of  milk  were  taken. 
It  has  been  shown  by  many  investigators  that  the  percentage  com- 
position of  human  milk  can  vary  within  very  wide  limits,  and  ob- 
viously there  must  be  a  corresponding  fluctuation  in  its  caloric 
value.  For  this  reason  many  of  the  computed  energy  quotients, 
based  upon  the  average  composition  of  human  milk,  are  criti- 

*  Quoted  by  Lusk:  The  Science  of  Nutrition,  Phila.  and  London,  1909,  41. 

*  Emery  and  Benedict:  Am.  Jour.  Phys.,  1911,  xxviii,  301.  Later  they 
showed  even  a  greater  difference  in  the  heat  of  combustion  of  lactose. 

'  An  excellent  review  of  the  Continental  work  may  be  found  in  Frank : 
Engergiequotient  und  Temperatur  im  Saulingsalter.  Inaug.  Dissert.  Mtinchen, 
1913. 

*  Heubner:  Kinderh.,  3  auflage,  Leipzig,  1911,  vol.  I. 


72  ENERGY  METABOLISM 

cised.  Heubner  ^  concluded  that  a  breast-fed  infant  did  not  gain 
satisfactorily  on  human  milk  during  the  first  three  months  when 
the  energy  quotient  fell  below  one  hundred  calories,  and  that 
when  the  energy  quotient  fell  below  seventy  calories  there  must 
be  a  loss  of  weight.  Schlossman  ^  on  the  other  hand  found  the 
best  gain  on  an  energy  quotient  of  one  hundred  and  ten  calories. 
Premature  infants  and  artificially-fed  infants,  according  to  Heub- 
ner, should  have  an  energy  quotient  of  not  less  than  one  hundred 
and  twenty  calories  dm-ing  the  first  three  months  of  life.  Feer  ' 
found  that  the  energy  quotient  of  Baby  Marianne,  the  composi- 
tion of  whose  food  was  known,  during  the  thirty-third  to  the 
forty-sixth  week  of  life  was  between  eighty-six  and  one  hundred 
and  four  calories.  He  beHeves  that  the  reason  artificially-fed 
infants  require  more  calories  than  the  breast-fed  is  that  the  work 
of  digestion  is  greater  in  the  former  than  in  the  latter.  Cramer  "* 
studied  the  energy  quotient  of  infants  during  the  first  nine  days 
of  life,  and  found  a  gain  of  from  fifty  to  sixty  grams  with  an  en- 
ergy quotient  of  less  than  fifty  calories.  Gaus  ^  confirmed  these 
findings  and  it  was  concluded  that  there  was  a  special  metabohsm 
for  infants  during  the  first  two  weeks  of  life.  There  is  no  doubt 
that  the  latter  observations  are  true,  and  that  during  the  first 
two  weeks  of  hfe  the  caloric  needs  are  very  low.  * 

The  caloric  requirements  then  increase  up  to  the  third  or 
fourth  month  at  which  time  they  are  close  to  those  given 
by  Heubner.  After  that  they  diminish  to  the  first  year  of  life. 
Two  infants,  aged  three  and  six  months  respectively,  studied 
at  the  Nutrition  Laboratory  of  the  Carnegie  Institution  of  Wash- 
ington by  Talbot  ^  showed  a  metabolism  of  100  and  94  calories 
respectively  per  kilogram  of  body  weight.  The  metabolism  of 
these  two  infants  was  measured  during  the  whole  of  twenty-four 
hour  periods  with  the  exception  of  short  periods  in  which  they 
were  removed  for  feeding. 

Siegert^  concluded  that  it  was  possible  for  the  breast-fed  in- 
fant to  gain  on  eighty  calories  per  kilogram  of  body  weight  dur- 

1  Heubner:  Jahrb.  f.  Kinderh.,  1910,  Ixxii,  121. 

2  Schlossmann:  Arch.  f.  Kinderh.,  1902,  xxxiii,  338. 
s  Feer:  Lehrbuch  der  Kinderh.,  2nd  Ed.,  1912. 

*  Cramer:  Mtinch.  med.  Wochenschr.,  1903,  2,  L,  1153. 

6  Gaus:  Jahrb.  f.  Kinderh.,  1902,  N.  F.  Iv,  129. 

*  Benedict  and  Talbot:  Physiology  of  the  New-Bom  Infant:  Carnegie  Ins., 
Wash.,  Publication  No.  233.  Murlin  and  Bailey:  Amer.  Jour.  Obstetrics 
and   Dis.  Women  and  Children,  1915,  Ixxi,  No.  3. 

7  Talbot.    Trans.  Am.  Ped.  Soc,  1917,  xxix.  39. 

*Siegert:  Versamml.  d.  Gesellsch.,  f.  Kinderh.,  Stuttgart,  1906. 


ENERGY  METABOLISM  73 

ing  the  first  three  months  of  life.  Czemy  and  Keller  *  consid- 
ered Heubner's  figures  too  high  and  report  an  infant  of  average 
weight  (Machill)  which  gained  regularly  on  an  average  of  seventy 
calories  per  kilogram  of  body  weight.  A  daily  examination  of  the 
milk  was  not  made.  Bundin  ^  fed  a  number  of  infants  on  mix- 
tures of  cow's  milk  which  gave  an  energy  quotient  of  seventy 
calories.  These  infants  were  of  the  average  or  of  less  than  the 
average  weight  and  gained  weight  consistently.  Oppenheimer  ^ 
gave  an  energy  quotient  of  one  hundred  and  eleven  calories  to  a 
normally  developed  infant  and  as  high  as  one  hundred  and 
forty-two  calories  to  an  infant  which  had  previously  been  underfed. 
Beck,  in  1904/  collected  the  Kterature  up  to  date  and  gives  the 
following  figures  as  an  average  energy  quotient  for  breast-fed 
infants: 

1-12  weeks 107  calories 

13-24  weeks 91  calories 

25-36  weeks 83  calories 

37-44  weeks 69  Queries 

He  concluded  that  artificially-fed  and  premature  infants  re- 
quired an  energy  quotient  of  from  one  hundred  and  twenty  to  one 
hundred  and  forty  calories.  Ladd  ^  gave  an  energy  quotient  which 
varies  between  ninety-three  and  one  hundred  and  fifty-nine  cal- 
ories. Dennett  *  concluded  that  the  average  normal  baby  will  do 
well  on  from  one  hundred  and  ten  to  one  hundred  and  twenty  cal- 
ories per  kilogram  and  that  very  emaciated  babies  require  from  one 
himdred  and  sixty  to  one  hundred  and  seventy  calories,  while 
those  who  are  only  moderately  emaciated  require  from  one  hun- 
dred and  thirty  to  one  hundred  and  fifty  calories.  Finally,  Fink- 
elstein,^  Gittings,*  and  Mayerhofer  and  Roth  ^  drew  attention  to 
the  fact  that  infants  who  were  under-weight  required  more  calo- 
ries than  well-developed  infants  and  advanced  the  suggestion  that 
they  require  as  many  calories  as  they  would  need  if  they  had  de- 
veloped in  the  normal  manner. 

^  Czemy  and  Keller:  Des  Kindes  EmShrung,  Ernahnmgsstanmgen,  und 
Erhahrungstherapie,  Leipzig  and  Wien,  1906,  vol,  i,  396. 

*  Bundin:  See  Czemy  and  Keller,  p.  404. 

'  Oppenheimer:  Arch.  f.  Kinderh.,  1909,  L.  355. 

*  Beck:  Monatsschr.  f.  Kinderh.,  1904-05,  iii,  206. 
•Ladd:  Archives  of  Pediatrics,  1908,  xxv,  178. 

*  Dennett:  Trans.  Section  on  EHs.  of  Children,  Amer.  Med.  Asso.,  1912,  186. 

*  Finkelstein:  Lehrbuch  der  Sauglingskrankheiten,  1905,  i,  54. 

*  Gittings:  Am.  Pediatric  Soc,  Stockbridge,  1914,  Reported  in  Jour.  A.  M. 
A.,  1914,  bdii,  55. 

» Mayerhofer  and  Roth:  Zeitschr.  f.  Kinderh.,  1914,  xi,  117. 


74  ENERGY  METABOLISM 

The  figures  just  given  as  to  the  cUnical  status  of  the  caloric 
requirements  of  different  infants  show  what  a  difference  of  opinion 
there  is  among  the  various  authorities.  There  can  be  Uttle  doubt 
that  in  the  main  they  are  all  correct,  if  one  bears  in  mind  the  pos- 
sibility of  error  in  such  rough  calculations  of  the  energy  metabo- 
lism of  infants.  Unfortunately,  the  accurate  measurement  of  the 
energy  metabolism  in  the  calorimeter  or  by  the  respiratory  ex- 
change is  only  for  shorter  or  longer  periods  of  the  twenty-four 
hour  day  and  does  not  give  exact  measurements  of  the  twenty- 
four  hour  metabolism.  It  is  necessary,  therefore,  to  depend  upon 
the  knowledge  of  the  basal  metabolism  of  a  large  number  of  in- 
fants and  to  attempt  to  correlate  this  with  the  results  of  clinical 
experience. 

The  metabolism  of  the  new-born  infant  has  been  recently 
studied  anew.^  After  birth  there  is  a  loss  of  weight  which  is  due 
to  two  distinct  causes : — 

1.  Mechanical. 

2.  Physiological. 

The  former  is  due  to  loss  of  meconium,  urine  and  vomited  ma- 
terial, while  the  latter  is  due  to  actual  loss  of  body  substance 
as  a  result  of  metabolism.  The  colostrum  does  not  supply 
enough  food  for  the  infant  in  the  first  three  days  of  life,  before 
the  breast  milk  "comes  in";  the  body  substance,  therefore,  has 
to  supply  what  is  necessary  for  the  infant's  vital  functions. 
The  respiratory  quotients  show  that  during  the  first  few  hours 
of  hfe  the  supply  of  glycogen  and  sugar  in  the  body  is  quickly 
exhausted,  and  that  the  body  must  then  subsist  on  its  own  fat. 
This  it  does  until  the  body  gets  enough  breast  milk  to  supply 
the  necessary  food.  There  is  also  a  distinct  correlation  be- 
tween the  body  temperature  and  the  general  metabolism,  for 
when  the  temperature  is  subnormal,  the  metabolism  is  low,  in- 
dicating that  all  the  vital  functions  are  below  par.  The  usual 
cause  of  the  subnormal  temperature  was  chilling  from  the  tub 
bath  or  exposure.  This  may  be  distinctly  dangerous  to  life.  The 
average  basal  metabolism  of  the  new-born  infant  from  13^  to  6 
days  of  life  is  44  calories  per  kilogram  of  body  weight,  and  it  is 
estimated  that  the  new-bom  infant  requires  62  calories  per  kilo- 
gram of  body  weight  in  its  food.  These  findings  teach  us  that 
all  precautions  should  be  taken  against  exposure  after  birth,  that 
the  water  cleansing  bath  may  be  dangerous  to  life  and  should, 
therefore,  not  be  used,  but  in  its  place  a  warm  oil  bath  may  be 

^Bailey  and  Murlin:  loc.  cit.  (6  infants);  Benedict  and  Talbot,  loc.  cU. 
(104  infants). 


ENERGY  METABOLISM  75 

given;  that  before  the  mother's  milk  "comes  in"  the  baby  does 
not  get  sufficient  food,  and,  therefore,  a  sugar  and  water  solution 
should  be  given  to  partly  make  up  the  deficit.  A  solution  of  5% 
lactose  proves  very  satisfactory. 

Metabolism  During  Starvation. — Very  few  observations  have 
been  made  on  the  metaboUsm  during  fasting,  and  nearly  all  of 
our  knowledge  comes  from  the  work  of  Schlossmann  and  Mur- 
schhauser  ^  in  the  Dusseldorf  Clinic  on  normal  infants.  They 
found  that  there  was  always  an  increased  nitrogen  elimination 
from  the  body  in  both  the  infant  that  had  been  artificially  fed 
or  breast  fed.  The  total  amount  lost  was  greater  in  the  former  than 
in  the  latter.  Less  nitrogen  was  lost  if  lactose  were  given  the 
infant  even  in  small  quantities.  The  blood  sugar  remained  nor- 
mal until  near  the  end  of  a  seventy-two  hour  fast  when  there  was 
a  sUght  fall.  After  twelve  hours  of  fast,  acetone  bodies  appeared 
in  the  urine  and  increased  in  amount  in  the  same  manner  as  during 
adult  fasting.  The  excretion  of  acetone  bodies  was  entirely  pre- 
vented by  giving  70  grams  of  lactose  in  the  day. 

Summary. — The  basal  metabolism  of  an  infant  is  the  metab- 
olism determined  after  the  taking  of  food,  with  the  infant  in 
complete  muscular  repose.  Comparison  of  infants  in  different 
states  of  nutrition  shows  that  roughly  the  normal  new-bom  infant 
has  a  basal  metabolism  of  44  calories  per  kilogram  of  body  weight, 
while  that  of  the  older  infant  is  about  55  to  60  calories  per  kilo- 
gram of  body  weight.  This  is  the  lowest  amount  of  energy  on 
which  a  baby  can  maintain  its  body  functions.  The  habits  of 
healthy  infants  vary  with  the  individual.  One  is  phlegmatic  and 
sleeps  most  of  the  day  and  night,  while  another  is  moving,  kick- 
ing or  crying  during  most  of  its  waking  hours.  It  has  been  shown 
that  the  metaboUsm  may  be  increased  from  forty  to  one  hundred 
per  cent  above  the  basal  metaboUsm  by  the  change  from  complete 
muscular  repose  to  active  exercise.  It  seems  probable,  therefore, 
that  the  infants  studied  by  Czemy,  Budin  and  their  followers  were 
placid  infants  who  conserved  their  energy  for  development,  and 
that  Heubner  and  his  followers  dealt  with  more  active  infants. 
It  is  necessary  to  add  certain  factors  to  the  calories  found  for  the 
basal  metabolism  for  muscular  exercise,  for  loss  of  energy  in  the 
feces,  and  for  growth.  These  can  only  be  estimated  by  studying 
the  habits  of  a  given  infant.  The  consensus  of  opinion  seems  to 
be  that  breast-fed  infants  require  less  energy  than  the  artificially- 
fed,  because  less  energy  is  required  to  make  the  food  available  for 

^  Schlossmann  and  Murschhauser:  Biochem.  Zeitschr.,  1913,  Ivi,  335; 
Schlossmann:  Biochem.  Zeitschr.,  1914,  Iviii,  493. 


76  ENERGY  METABOLISM 

the  body.  This  may  be  the  sole  explanation,  or  it  may  be  that  the 
difference  in  their  requirements  is  due  to  the  fact  that  the  breast- 
fed infant  is  on  the  average  a  quieter  infant  and  that  it  sleeps 
more  than  the  artificially-fed  infant. 

Babies  that  weigh  more  than  the  average  weight  for  their  age 
and  new-born  infants  have  usually  a  basal  metabolism  of  between 
forty  and  fifty-two  calories  per  kilogram  of  body  weight.  Both  the 
new-bom  and  fat  infants  are  quieter  than  infants  which  have 
developed  their  muscles  and  as  a  result  the  energy  required  for 
muscular  work,  which  must  be  added  to  their  basal  energy  metab- 
oHsm,  is  less  than  it  is  in  active,  crying  infants.  The  large  fat 
babies  which  weigh  more  than  the  average  will,  therefore,  gain 
more  weight  on  a  low  energy  quotient  than  babies  of  average 
weight.  The  new-bom  infant  falls  into  this  class  as  it  has  a  rela- 
tively large  proportion  of  fat  and  a  small  proportion  of  muscle. 

Moderately  emaciated  or  atrophic  infants  have  a  higher  basal 
metabolism  than  do  the  babies  of  average  weight.  It  varies  be- 
tween sixty-three  and  eighty-seven  calories  per  kilogram  of  body 
weight.  When  the  energy  required  for  muscular  work  is  added  to 
this,  the  energy  quotient  is  the  result.  It  must  be  remembered, 
however,  that  infants  of  this  type  that  have  many  loose  undigested 
stools  may  lose  twenty  per  cent  ^  or  more  of  the  energy  of  the  food. 
Some  under-weight  infants  require  many  more  than  the  120  calories 
per  kilogram  of  body  weight,  which  is  considered  the  high  normal 
figure.  If  the  infant  is  very  weak  and  quiet,  a  small  increase  in 
the  number  of  calories  above  the  basal  requirements  will  be  sufii- 
cient  to  enable  it  to  gain  in  weight.  If,  on  the  other  hand,  it  is 
crying  from  morning  to  night  because  of  either  hunger  or  dis- 
comfort, a  very  much  greater  percentage  of  calories  must  be  added 
to  the  basal  requirements  in  order  that  it  may  grow.  There  laso 
can  be  little  doubt  that  in  weak  babies  energy,  which  would  other- 
wise be  used  to  keep  the  baby  warm,  can  be  conserved  by  increas- 
ing the  temperature  of  the  infant's  surroundings.  The  infant  that 
is  under-weight  requires,  therefore,  somewhere  between  one  hun- 
dred and  thirty  and  one  hundred  and  sixty  calories  per  kilogram 
of  body  weight.  The  normal  new-bom  infant  requires  approxi- 
mately 62  calories  per  kilogram  of  body  weight.  The  energy 
requirement  increases  in  the  first  quarter  year  up  to  between 
100  and  120  calories  and  then  gradually  falls  so  that  at  the  end 
of  the  first  year  the  normal  infant  needs  between  70  and  80  cal- 
ories per  kilogram  of  body  weight.  These  figures  are  modified 
by  the  individual  peculiarities  of  the  infant. 

^  Benedict  and  Talbot:  Am.  Jour.  Dis.  Children,  1914,  viii,  1. 


CHAPTER  VII 
BACTERIOLOGY  OF  THE  GASTROINTESTINAL  CANAL  » 

BACTERIOLOGY   OF   THE   MOUTH 

The  infant's  mouth  is  sterile  before  birth,  but  becomes  infected 
from  the  mother's  vagina  during  birth,^  or  from  the  air  soon 
after  birth.^  The  variety  of  organisms  present  at  this  time  is 
relatively  small,  but  as  soon  as  the  infant  commences  to  take 
food  the  flora  becomes  more  complicated.  The  number  of  bac- 
teria does  not,  however,  increase  materially.  When  the  infant 
takes  breast  milk,  there  is  an  increase  in  the  variety  of  the  or- 
ganisms, and  pathological  bacteria  even  may  be  found  in  the 
mouths  of  healthy  babies.^  Because  of  the  fact  that  even  the 
purest  cow's  milk  contains  more  bacteria  than  hiunan  milk  it  is 
reasonable  to  expect  that  the  mouths  of  babies  fed  on  the  bottle 
will  contain  a  greater  variety  of  bacteria  than  those  fed  at  the 
breast  and  that  the  dirtier  the  milk  the  greater  will  be  the  variety  of 
the  organisms.  There  are,  however,  no  data  as  to  whether  this  is 
true  or  not.  After  the  eruption  of  teeth,  i.  e.,  after  the  infant  is  six 
months  old,  the  number  and  variety  of  the  bacteria  increase  ^  and 
certain  microorganisms,  such  as  the  Leptothrix,^  and  fusiform 
bacteria,^  which  are  apparently  only  able  to  obtain  a  foothold  in 
the  mouth  when  teeth  are  present,*  appear. 

It  is  an  open  question  as  to  how  important  a  part  the  bacteria  of 

*  G.  Bessau  in  Tobler,  Allegemeine  Pathologische  Physiologie  der  Er- 
n'ahrung  und  des  Stoffwechsels  im  Kindesalter,  Wiesbaden,  1914,  has  been 
freely  used  in  this  chapter  and  many  of  the  statements  have  been  taken 
directly  from  it.  It  may  be  consulted  by  those  who  wish  to  go  into  the  subject 
more  deeply. 

*Kneise:  Sittler  quoted  by  Tobler. 
» Campo:  La  Pediatria,  1899,  vii,  229. 

*  Doernberger:  Jahrb.  f.  Kinderh.,  1893,  xxxv,  395;  Herzberg:  Deutch. 
med.  Woch.,  1903,  xxix,  17. 

*  Noblccourt  and  Vicaris:  Arch.  gen.  de  Med.,  1905,  2,  3201,  ref.  Monats- 
schr.  f.  Kinderh.,  1905-6,  iv,  640. 

*  Oshima:  Arch.  f.  Kinderh.,  1907,  xlv,  21. 

»  Uffenheimer:  Munch,  med.  Woch.,  1904,  1198,  1253;  Ergebnisse  d.  inn. 
Med.  u.  Kinderh.,  1908,  ii,  304. 

*  For  a  more  detailed  account  of  the  flora  of  the  mouth  E.  Kuster  in  Kolle 
Wasserman's  Handbuch,  II  ed.,  Jena,  1913,  vi,  435,  may  be  consulted. 

77 


78  BACTERIOLOGY 

the  mouth  play  m  the  digestion  processes  in  the  stomach.  It  is 
conceivable  that  these  bacteria,  especially  when  there  is  dental 
caries,  may  do  harm.  It  has  not  been  proven,  however,  that  they 
do. 

BACTERIOLOGY  OF  THE   STOMACH 

The  same  influences  which  modify  the  bacterial  flora  of  the 
mouth  modify  that  of  the  stomach.  Under  physiological  con- 
ditions the  bacteria  in  the  stomach  play  an  unimportant  r61e. 
A  description  of  the  individual  kinds  may  be  found  in  the  works 
of  Escherich  ^  who  was  a  pioneer  in  this  field  of  investigation. 
The  smallest  numbers  are  found  in  the  stomachs  of  the  breast- 
fed,^ and  they  remain  relatively  scarce  as  long  as  the  digestion 
is  normal.  When  there  is  indigestion,  there  is  an  increase  in 
their  numbers.  The  greatest  numbers  are  found  in  cholera  in- 
fantum.^ 

Bactericidal  Powers  of  the  Stomach. — Free  hydrochloric  acid 
is  able  to  destroy  bacteria  in  the  stomach.^  There  is  no  doubt 
that  it  is  strongly  attracted  by  the  proteins  of  the  food  and  quickly 
combines  with  them,  thus  becoming  inert.  Furthermore,  the  casein 
in  the  milk  is  rapidly  coagulated  into  curds.  The  disinfecting 
action  of  the  hydrochloric  acid  can  only  be  effective  on  the  sur- 
face of  the  curds,  and  the  large  numbers  of  bacteria  which  are 
present  in  the  interior  of  the  curds  are  not  reached  by  it.^  The 
number  of  bacteria  in  the  stomach  apparently  depends  also  on 
the  activity  of  the  gastric  motility,  for  the  quicker  the  stomach 
is  emptied,  the  fewer  are  the  bacteria  which  it  contains.  The 
converse  is  also  true. 

Lactic  acid  fermentation  does  not  seem  to  play  as  important  a 
part  in  the  stomach  of  the  infant  as  it  does  in  that  of  the  adult  in 
which  it  occurs  only  when  hydrochloric  acid  is  absent.  Lactic  acid 
is  seldom  or  never  found  in  the  stomach  of  the  breast-fed,  but  is  fre- 
quently found  in  small  amounts  in  the  stomachs  of  infants  fed  on 
cow's  milk.^ 

Butyric  acid  fermentation  is  more  common,^  and  has  been 
found  to  occur  in  the  stomachs  of  atrophic  infants  in  which  the  ex- 
cretion of  hydrochloric  acid  and  the  motility  are  both  diminished. 

^  Escherich:  Die  Darmbakterien  des  Sauglings,  Stuttgart,  1886. 

*  Van  Puteren:  Ref.  Zeitschr.  f.  mikroskopie,  1888,  v,  539. 
» Seiffert:  Jahrb.  f.  Kinderh.,  1891,  xxxii,  392. 

*  Hamburger:  Ueber  die  Wirkung  des  Magensaftes  auf  pathogene  Bakterien. 
Inaug.  Diss.  Breslau,  1890,  quoted  by  Tobler. 

'  Tobler:  Ergeb.  d.  inn.  Med.  u.  Kinderh.,  1908,  i,  495. 
•Cassel:  Arch,  f,  Kinderh.,  1890,  xii,  175. 


BACTERIOLOGY  79 

The  pasteurization  or  boiling  of  milk  destroys  the  organisms  which 
produce  lactic  acid  but  does  not  kill  the  spore-bearing  bacilli/ 
which  produce  butyric  acid.  The  latter  causes  the  formation  of 
butyric  acid  from  carbohydrates  and  fat  and  possibly  from  protein. 
Whether  butyric  acid  is  formed  or  not  depends,  according  to  Tob- 
ler,  not  on  the  kind  of  food  present,  but  on  the  type  of  bacteria. 
This  may  be  in  part  true,  because  fermentation  cannot  take  place 
without  fermentative  organisms.  On  the  other  hand,  however, 
the  food  components  necessary  for  fermentation  must  be  present 
in  sufficient  quantitj'^  to  supply  the  bacteria  with  fermentable 
material.  The  lactic  acid  bacilli  and  the  butyric  acid  bacilli  are 
the  only  organisms  which  usually  play  a  part  in  the  various  proc- 
esses of  acid  production  in  the  stomach.  The  other  bacteria  (B. 
bifidus,  B.  acidophilus,  B.  coli  and  B.  lactis  aerogenes),  which 
form  acid  are  usually  foimd  only  in  the  lower  intestinal  canal. 

BACTERIOLOGY   OP  THE   UPPER   PART  OF  THE   SMALL   INTESTINE 

The  upper  part  of  the  small  intestine,  in  comparison  with  the 
rest  of  the  digestive  canal,  is  relatively  free  from  bacteria,  both  in 
the  breast  and  in  the  bottle-fed  infant,  especially  during  fasting. 
Hess  ^  studied  the  bacteria  of  the  duodenum  during  life  by  an 
ingeniously  devised  modification  of  his  duodenal  catheter.  He 
found  that  in  the  new-bom  infants,  who  had  received  no  food, 
the  duodenum  contained  very  few  organisms,  only  from  one  to 
three  growing  on  a  plate.  The  organisms  were  staphylococci, 
Gram  positive  and  Gram  negative  bacilli.  Colon  bacilli  were 
not  found.  Infants  in  the  first  week  of  Hfe  also  had  very  few 
bacteria  in  the  duodenum  and  these  were  of  the  same  varieties  as 
those  found  soon  after  birth.  There  was  more  or  less  similarity 
between  the  bacteria  of  the  stomach  and  the  duodenum.  The 
staphylococcus  was  the  organism  most  frequently  found  at  this 
age.  Hess  could  not  establish  any  relation  between  the  amount 
of  hydrochloric  acid  in  the  stomach,  or  of  bile  in  the  duodenum, 
and  the  number  of  bacteria.  The  presence  or  absence  of  icterus 
made  no  difference  in  the  bacteriology  of  the  duodenum  in  these 
babies.  Cultures  from  the  duodenal  contents  of  older  breast-fed 
babies  showed  from  one  hundred  to  two  hundred  colonies  per 
plate.    The  plate  method  would  not  be  satisfactory  for  an  aero- 

1  (Bodkin's  butjnric  acid  bacillus  appears  to  be  relatively  rare  and  it  is  possi- 
ble that  the  gas-bacillus,  which  also  forms  butyric  acid,  is  the  one  that  is 
ordinarily  found.) 

=*  Hess:  Ergebnisse  der  inn.  Med.  u.  Kinderh.,  1914,  xiii,  p.  530. 


80  BACTERIOLOGY 

bic  organism  such  as  the  bacillus  bifidus,  which  may  also  be 
found  in  this  region.  It  must  be  remembered,  therefore,  that 
these  results  may  not  represent  the  true  condition.  Those  from 
bottle-fed  infants  showed  many  more.^ 

There  is  evidence  that,  while  the  duodenum  may  be  practically 
free  from  bacteria  during  the  intervals  between  digestion,  there 
is  a  relatively  large  population  in  the  small  intestine  while  the  food 
is  passing  through  it.^  According  to  Ficker  ^  and  Moro  ^  the  flora 
of  the  upper  small  intestine  is  composed  principally  of  short  Gram 
negative  rods  (colon  bacillus  and  bacillus  lactis  aerogenes)  with 
an  occasional  isolated  bacillus  bifidus  communis,  bacillus  acido- 
philus and  butyric  acid  bacillus,  and  enterococci. 

Moro  ^  believes  that  there  can  be  an  endogenous  infection  of 
the  small  intestine.  Such  an  infection  is  probably  present  in  most 
disturbances  of  nutrition,  both  acute  and  chronic.  The  epidemic 
of  severe  diarrhea,  associated  with  the  presence  of  inflammatory 
products  in  the  stools  (blood  and  pus),  described  by  Escherich  ^ 
has  been  used  as  evidence  for  this  point  of  view.  The  infants 
attacked  were  all  young,  their  ages  varying  from  four  to  ten 
months.  The  stools  contained  bacteria,  which  he  called  "blaue 
Bacillose"  and  which  were  proved  to  be,  almost  without  question, 
"aciduric"''  or  acidophiUc  organisms.  These  organisms  were 
probably  identical  with  those  which  are  normally  present  among 
the  flora  of  the  healthy  nursling.  Logan  ^  on  the  other  hand  was 
unable  to  show  that  any  colon-like  organisms  from  cases  with 
diarrhea  showed  any  greater  virulence  to  guinea  pigs  than  the 
same  organisms  from  babies  not  suffering  from  diarrhea. 

BACTERIOLOGY  OF  THE  LOWER  PART  OF  THE  SMALL  INTESTINE  AND 
OF  THE   LARGE   INTESTINE 

There  are  relatively  fewer  bacteria  in  the  healthy  small  intes- 
tine down  to  the  lower  part  of  the  ileum.  There  they  begin  to 
increase  in  number  so  that  when  the  large  intestine  is  reached 

^  Moro;  Jahrb.  f.  Kinderh.,  1905,  Ixi,  870,  may  be  consulted  for  the  litera- 
ture. 

2  Moro:  Arch.  f.  Kinderh.,  1906,  xliii,  340;  Kohlbrugge:  Cent.  f.  Bact., 
Orig.  1901,  xxix,  571;  Landsberger:  Diss.  Konigsberg,  1903,  quoted  by  Kendall. 

3  Ficker:  Arch.  f.  Hyg.,  1905,  liv.  354. 
*Moro:  Arch.  f.  Kinderh.,  1906,  xliii. 

*Moro:  Munchen.  Gesellsch.  f.  Kinderh.,  1907,  xi,  15. 
"Escherich:  Jahrb.  f.  Kinderh.,  1900,  52,  1. 
^Kendall:  Jour.  Med.  Research,  1911,  xx,  117. 
'Logan:  Jour.  Path,  and  Bact.,  1914,  xviii,  527. 


BACTERIOLOGY  OF  STOOLS  81 

they  are  very  numerous.  The  types  of  bacteria  which  are  com- 
monly found,  according  to  Kendall,  are  as  follows:^  The  more 
commonly  recognized  bacteria  are  the  B.  bifidus  (Tissier),  the 
Mic.  ovalis,  the  B.  coli,  the  B.  lactis  aerogenes,  and  the  B.  acido- 
philus (Moro).  These  make  up  the  fecal  flora  of  the  normal  nurs- 
ling. The  B.  lactis  aerogenes  appears  in  the  upper  levels  of  the 
tract,  that  is,  the  duodenum  and  jejunum;  the  Mic.  ovalis  in  the 
lower  jejunum  and  in  the  ileum  to  the  ileoca;cal  valve;  the  B.  coU 
and  the  B.  acidophilus  in  the  region  of  the  ileocaecal  valve,  while 
the  B.  bifidus  appears  to  dominate  the  ascending  and  transverse 
colon.  This  cannot  be  accepted  without  reservation  since  intes- 
tinal bacteriology  is  by  no  means  so  simple  as  it  would  appear  from 
the  foregoing  statement.  The  remainder  of  the  tract  to  the  anus 
is  relatively  poorly  populated  in  relation  to  the  coecum  so  far  as 
living  bacteria  are  concerned.  This  is  due  in  part  to  the  consid- 
erable degree  of  desiccation  of  the  fecal  contents  of  the  intestines 
and  in  part  to  the  accumulation  of  waste  products,  which  appear 
to  inhibit  the  development  of  bacteria. 

The  character  of  the  bacteria  in  the  large  intestine  depends 
largely  upon  the  food,^  and,  since  human  milk  is  a  relatively  homo- 
geneous food,  the  tendency  of  the  bacteriological  flora  of  the  breast- 
fed is  toward  uniformity.  The  bacteriological  conditions  in  the 
artificially  fed  are,  as  would  be  expected,  less  consistent,  because 
there  is  less  uniformity  in  the  food  which  they  receive,  and  because 
cow's  milk  is  rarely  sterile.  The  distinctive  features  of  the  stools 
of  the  artificially  fed  are  the  relative  increase  of  Gram  negative 
bacilli  of  the  colon-aerogenes  type  and  of  cecal  forms  of  the  Mic. 
ovaHs  types.  Coincidently,  there  is  a  decrease  in  the  number  of 
organisms  of  the  B.  bifidus  type.  The  B.  acidophilus  is  relatively 
more  numerous  and  the  B.  bifidus  less  numerous. 

BACTERIOLOGY   OF   THE   STOOLS 

The  first  stools  (meconium),  of  the  new-bom  are  sterile,  but 
they  become  infected  shortly  after  birth.  Within  eighteen  to 
twenty-four  hours  after  birth,  bacteria  make  their  appearance 
in  the  stools  and  the  meconium  begins  to  disappear.  The  kinds 
and  the  number  of  bacteria  which  are  found  depend  largely  upon 
the  season  and  the  environment  of  the  infant.'  This  is  a  period 
of  mixed  infection.     The  following  organisms  have  been  found 

'Kendall:  Jour.  Med.  Research,  1911-12,  xx,  117. 

*  Moro :  loc.  cil. 

*  Kendall:  Wisconsin  Med.  Jour.,  1913,  xii,  No.  1. 


82  BACTERIOLOGY  OF  STOOLS 

in  meconium:  B.  subtilis,  B.  coli/  B.  bifidus,  B.  putrificus  (Bien- 
stock),  butyric  acid  bacillus,^  and  enterococci.^  These  organisms 
undoubtedly  gain  entrance  to  the  intestinal  canal  through  both 
the  mouth  and  the  anus.  Meconium  is  a  poor  culture  medium, 
probably  because  of  its  small  water  content. 

The  B.  bifidus  appears  about  the  beginning  of  the  third  day  and 
persists  throughout  the  nursing  period.  It  is  an  obUgate  anaerobe 
(Kendall),  Gram  positive,  and  is  the  most  characteristic  organism 
of  the  nursling's  stool.  It  is  apparently  independent  of  the  quality 
of  the  stool  and  is  present  in  the  classical  golden-yellow,  homog- 
eneous, pasty  stool  as  well  as  in  those  which  deviate  from  this 
character  in  consistency  and  color.^  Although  the  B.  bifidus  dom- 
inates the  typical  field,  other  Gram  positive  bacteria  can  always 
be  found.  Other  bacteria  that  have  been  described  in  the  stools 
of  the  nursling  are  cocci,  the  B.  lactis  aerogenes,  the  B.  coli,  the 
B.  acidophilus,  butyric  acid  bacillus,  the  B.  mesentericus  and  the 
B.  aerogenes  capsulatus  (Welch). 

The  bacteriology  of  the  stools  of  the  artificially-fed  infant  is 
much  more  complicated  than  that  of  the  breast-fed.  No  charac- 
teristic type  of  bacteria  predominates,  but  there  is  a  mixture  of 
bacterial  types.  Culturally,  the  same  species  are  found  as  in  the 
stools  of  the  breast-fed  infant.  The  general  picture  is,  however, 
apt  to  be  Gram  negative  in  contradistinction  to  that  of  the  stool 
of  the  breast-fed  infant,  which  is  usually  Gram  positive.  The 
B.  coh  commimis,  and  the  B.  lactis  aerogenes  are  the  most  numer- 
ous of  these  predominating  Gram  negative  bacteria.  A  peptoniz- 
ing bacillus,  which  is  almost  always  absent  from  the  stools  of  the 
breast-fed,  has  been  recorded  by  Rodella.^  Passini  *  found  these 
types  of  butyric  acid  forming  organisms,  and  isolated  peptonizing 
organisms  from  the  stools  of  apparently  normal  bottle-fed  babies. 
The  B.  putrificus,  the  most  typical  example  of  a  purely  proteolytic 
organism,  has  been  found  in  several  cases. 

The  discussion  as  to  the  causes  which  influence  the  appearance 
and  disappearance  of  certain  bacteria  is  of  more  than  polemic  in- 
terest, since  it  may  lead  to  some  conclusions  which  will  have  a 
practical  application.  Kendall's^  view  is  given  as  follows:  "The 
intestinal  tract  is  sterile  at  birth,  because  the  uterine  cavity  is 

^Escherich:  loc.  cit. 

2Moro:  Jahrb.  f.  Kinderh.,  1905,  Ixi,  885. 

*  Sittler:  Habititationsschr.,  Wurzburg,  1909,  quoted  by  Tobler. 

<Moro:  Jahrb.  f.  Kinderh.,  1905,  Ixi,  687. 

6  RodeUa:  Zeits.  f.  Hyg.,  1902,  xli,  466. 

•Passini:  Zeits.  f.  Hyg.,  1905,  xhx,  135. 

'  Kendall:  Wisconsin  Med.  Join:.,  1913,  xii,  No.  1. 


BACTERIOLOGY  OF  STOOLS  8a 

sterile.  The  first  infection  takes  place  adventitiously.  Any 
organisms  which  enter  by  the  mouth  or  through  the  anus  in  the 
ba^h  water,  which  can  exist  at  body  temperature,  may  find  lodg- 
ment in  the  intestinal  tract  and  may  temporarily  grow  there. 
Many  of  the  bactera  which  thus  succeed  in  entering  the  alimen- 
tary canal  are  spore-forming.  During  this  period  the  food  which 
is  presented  to  them  is  largely  detritus  of  fetal  origin.  At  the 
beginning  of  the  third  day,  when  the  breast  milk  has  had  a  chance 
to  throughly  permeate  the  intestinal  tract,  new  organisms  appear, 
organisms  which  have  a  definite  relationship  to  the  type  of  food 
which  is  presented  to  them.  It  will  be  remembered  that  breast 
milk  contains  essentially  7%  of  lactose,  about  3%  of  fat,  and  but 
1/^%  of  protein.  Carbohydrate  is,  therefore,  the  dominant  food. 
It  is  noteworthy  that  the  organisms  which  appear  in  response 
to  this  diet  are  those  whose  metaboHsm  is  intimately  associated 
with  the  utUization  of  sugar.  These  organisms  thrive  but  poorly 
in  a  medium  from  which  sugar  is  excluded.  When  other  foods 
begin  to  replace  the  breast  milk  there  is  a  definite  change  in  the 
types  of  bacteria  represented  in  the  intestinal  contents.  The  ob- 
hgate  fermentative  bacteria,  such  as  the  B.  bifidus,  are  replaced 
by  more  plastic  forms  and  by  the  B.  coli  which  can  accommodate 
their  metabohsm  rapidly  to  dietary  alterations.  The  B.  coU  for 
example  can  thrive  equally  well  on  a  medium  in  which  carbohy- 
drate is  absent.  It  might  appear  from  this  rather  definite  altera- 
tion of  types  of  bacteria  in  the  intestinal  tract  following  changes  in 
the  character  of  the  food,  that  the  food  alone  determined  the 
intestinal  flora.  This  may  be  somewhat  influenced  by  the  intes- 
tinal secretions.  The  essential  feature,  however,  is  the  very  direct 
relationship  between  the  food  and  the  bacterial  reponse  to  it.  This 
recognition  of  a  relationship  between  food  and  bacteria  in  the  intes- 
tinal tract  is  important  in  considering  the  intestinal  flora,  for  it 
correlates  the  metabolism  of  the  flora  with  the  effects  which  it 
produces  rather  than  attempting  to  establish  indistinct  relations 
between  the  morphology  of  the  flora  and  these  effects."  These 
conclusions  are  supported  by  the  work  of  Sittler,^  and  Bahrdt  and 
Beifeld.2 

Ford  and  Blackfan^  produce  evidence  that  "the  bacteria  with, 
which  the  food  is  infected  are  almost  the  same  as  those  found  in 
the  dejecta  of  the  children  fed  on  these  foods."   Sisson,  however,* 

» Sittler:  Centralbl.  f .  Bakteriol,  1908,  xlvii,  14  and  145. 

*  Bahrdt  and  Beifeld:  Jahrb.  f.  Kinderh.,  1910,  Ixxii,  Erganzungsheft,  71. 
'Ford  and  Blackfan:  Am.  Jour.  Dis.  Ch.,  1917,  xiv,  354. 

*  Sisson:  Am.  Jour.  Dis.  Ch.,  1917,  xiii,  117. 


84  '  BACTERIOLOGY  OF  STOOLS 

was  unable  to  cause  any  striking  change  in  the  intestinal  flora 
of  puppies  by  increasing  the  sugars  in  the  food.  Rettger,^  found 
that  by  feeding  lactose  the  B.  acidophilus  and  the  B.  bifidus 
became  the  predominating  types. 

Bluhdom  ^  studied  the  intestinal  flora  of  infants  and  found  that 
greater  acidity  was  formed  in  human  milk  than  in  cow's  milk. 
He  also  found  that  lactose  and  maltose  were  more  easily  broken 
down  by  the  intestinal  flora  of  infants,  than  was  cane  sugar.  Malt 
extract  produced  greater  acidity  than  maltose. 

Further  investigations  are  necessary  to  throw  more  light  on  the 
subject  which  is  not  as  simple  as  it  appears.  It  seems  probable 
that  other  factors  besides  the  sugar  alone  may  play  an  important 
part  in  determining  the  intestinal  flora,  most  important  of  which 
is  the  relation  of  the  sugar  to  the  other  food  components,  especially 
those  which  favor  putrefaction.^ 

It  has  been  shown  by  Herter  and  Kendall  *  that  when  monkeys 
were  fed  on  milk  fermented  with  the  bacillus  bulgaricus  it  was 
possible  to  maintain  an  acid  reaction  throughout  the  intestinal 
tract,  the  acidity  growing  less  marked  below  the  ileocecal  valve. 
After  feeding  the  bacillus  bulgaricus  over  a  prolonged  period, 
it  may  be  found  in  large  numbers  in  the  small  intestine,  while 
only  a  very  few  can  be  demonstrated  in  the  large  intestine.  Raehe  ^ 
showed  that  this  organism  cannot  become  adapted  to  the  human 
large  intestine.  Rettger®  concludes  that  "ingestion  of  foreign 
bacteria  even  in  large  numbers  does  not  in  itself  bring  about 
an  elimination  or  displacement  of  the  common  intestinal  micro- 
organisms." 

It  is  interesting  to  note  that  Noguchi  ^  in  studying  the  growth 
and  characteristics  of  the  B.  bifidus  was  able  to  transform  it  in 
the  laboratory  from  the  strictly  anerobic  type  (B.  bifidus,  Tissier) 
to  the  facultative  aerobic  type  (B,  acidophilus,  Moro)  and  back 
again  to  the  anerobic  type.  Logan  ^  believes  that  the  B.  bifidus 
of  the  breast-fed  is  replaced  by  the  B.  acidophilus  in  the  bottle-fed. 

The  Number  of  Bacteria  in  the  Stools. — ^The  most  reliable 
figures  as  to  the  bacterial  content  of  infants'  stools  are  those  ob- 

^  Rettger:  Centralbl.  f.  Bacteriologie,  1914,  Ixxiii,  362,  Jour.  Exper.  Med., 
1915,  xxi,  365. 
'  Bluhdorn:  Monat.  f.  Kinderh.,  1915,  xiii,  297. 
"^  For  a  discussion  of  the  action  of  the  different  sugars  see  Tobler. 
"  Herter  and  Kendall:  Jour.  Biol.  Chem.,  1908,  v,  293. 
^  Raehe:  Jour.  Infect.  Dis.,  1915,  xvi,  210. 

*  Rettger:  loc.  dl. 

^  Noguchi:  Jour.  Exper.  Med.,  1910,  xii,  182. 

*  Logan:  Jour.  Path,  and  Bact.,  1914,  xviii,  527. 


BACTERIOLOGY  OF  STOOLS 


85 


tained  by  Strassburger's  method.^  This  method  is  open  to  great 
sources  of  error.  There  is  no  suitable  clinical  method.  He  found 
that  the  bacterial  content  of  infants'  stools  was  as  follows: 

TABLE   16 


Age 

Food 

Digestion 

Per  cent  of  bacteria  in 
the  dried  stool 

2  months 

4H     " 
5 
2 
1 

cow's  milk 

((          <( 

tt          « 

human  milk 

<<        <( 

normal 

11 

? 

normal 
dysp>eptic 

11.5 
42.3 
35.2 
25.8 
61.4 

Leschziner  ^  found  that  2%  to  28.4%  of  the  dried  stool  of  the 
healthy  breast-fed  infant  was  composed  of  bacteria,  while  from 
6.52%  to  29.4%  of  the  total  nitrogen  was  derived  from  bacteria. 
The  newer  and  more  perfect  methods  of  Kramsztyk  '  and  Klotz  * 
show  that  the  number  of  fecal  bacteria  varies  with  the  kind  of 
food  and  that  it  is  the  chemical  composition  of  the  food  rather 
than  its  bacterial  content  which  is  of  significance.  Escherich  * 
has  shown  that  steriUzation  of  the  food  has  very  httle  or  no  in- 
fluence on  the  number  of  fecal  bacteria.®  Kramsztyk  found  the 
smallest  number  in  the  stools  of  infants  fed  on  the  breast.  He 
found  more  in  the  stools  of  those  fed  on  diluted  cow's  milk,  and 
most  in  the  stools  of  those  taking  both  human  and  cow's  milk. 
Carbohydrates,  especially  in  the  form  of  malt  extract,  increase 
the  number  of  bacteria.  Klotz,  whose  figures  are  somewhat 
higher,  found  that  the  maximum  amount  of  fecal  bacteria  in  the 
dried  feces  is  from  30%  to  36%.  He  also  found  the  smallest 
numbers  in  soap  stools.  Strassburger,  however,  found  that  60% 
of  the  dyspeptic  stool  was  made  up  of  bacteria.  Although  count- 
ing the  number  of  Uving  bacteria  is  attended  with  many  dif- 
ficulties there  can  be  but  httle  doubt  that  a  large  proportion  of 
the  fecal  bacteria  are  dead.^ 

Pathogenic  Bacteria. — ^The  typhoid  bacillus  and  the  various 

»  Strassburger:  Zeits.  f.  klin.  Med.,  1902,  xlvi,  413. 
*  Leschziner:  Deutsch.  aerzte  Zeitimg,  1903,  No.  17,  169. 
» Kramsztyk:  Zeits.  f.  Kinderh.,  1911,  i,  169. 
♦Klotz:  Jahrb.  f.  Kinderh.,  1911,  Ixxiii,  391. 
»  Escherich:  Centralbl.  f.  BacterioL,  1887,  ii,  633  and  664. 
•For  further  hterature  consult  Gerhard,  Erg.  d.   Physiol.   (Asber-Spiro 
1904,  L.  107.) 
7  Eberle:  Centralbl.  f.  BacterioL,  1896,  19,  2. 


86  BACTERIOLOGY  OF  STOOLS 

typ^  of  paratyphoid  bacilli  may  be  present  in  the  stools  of  infants 
under  the  same  conditions  as  in  adults.  The  same  is  true  of  the 
tubercle  bacillus  and  the  cholera  bacillus,  as  well  as  of  other  un- 
common microorganisms,  such  as  the  bacillus  of  anthrax. 

The  various  types  of  the  dysentery  bacillus  are  frequently  found 
in  the  infants.  When  these  organisms  are  found  in  considerable 
numbers  in  association  with  the  sjonptoms  of  disease  of  the  intes- 
tinal tract,  as  in  infectious  diarrhea,  they  are,  in  most  instances, 
the  cause  of  the  disease.  Ten  Broeck,^  found  the  bacillus  dys- 
enteriae  of  the  mannite  fermenting  group  in  the  circulating  blood 
of  an  infant  suffering  with  infectious  diarrhea.  Eleven  negative 
findings  in  infants  with  infectious  diarrhea  lead  him  to  conclude 
that  the  one  positive  finding  was  accidental  rather  than  a  usual 
feature  of  the  disease.  When  large  numbers  of  streptococci  are 
found  in  association  with  fever  and  diarrhea  it  may  be  assumed 
that  the  streptococcus  is  the  cause  of  the  diarrhea.  The  presence 
of  a  few  of  these  organisms  in  the  stools  in  cases  of  diarrhea  does 
not  prove,  however,  that  they  are  the  cause  of  the  symptoms. 
They  also  may  sometimes  be  found  in  small  numbers  in  the  normal 
stools  of  apparently  healthy  infants.  Under  these  circimistances 
they  are  to  be  regarded  simply  as  saprophytes. 

Knox  and  Ford  ^  concluded  from  their  examinations  of  the  stools 
that  the  gas  bacillus  is  a  constant  inhabitant  of  the  intestinal 
tract  in  all  infants  except  those  who  are  breast-fed.  Ten  Broeck 
and  Norberry  ^  came  to  similar  conclusions,  but  do  not  give  it  the 
same  etiological  significance  as  does  Kendall. 

*  Ten  Broeck:  Boston  Med.  &  Surg.  Jour.,  1915,  clxxiii,  284. 

'  Knox  and  Ford:  Bull.  Johns  Hopkins  Hosp.,  1915,  xxvi,  p.  27. 

'  Ten  Broeck  and  Norberry:  Boston  Med.  &  Surg.  Jour.,  1915,  clxxiii,  280. 


CHAPTER  Vin 
THE  STOOLS  IN  INFANCY 

The  examination  of  the  stools  is  of  the  greatest  aid  in  the  diag- 
nosis of  the  nature  of  disturbances  of  digestion  in  infancy.  It 
furnishes  information  which  cannot  be  obtained  so  quickly  and 
accurately  in  any  other  way.  The  clinical  examination  of  the 
stools  is,  moreover,  not  a  difficult  matter.  It  requires  but  httle 
time  and  but  Uttle  apparatus.  The  methods  are  simple  and  easy 
to  learn.  It  is  fortunately  not  necessary  to  make  use  of  the  more 
compUcated  methods  of  analysis  in  every-day  work,  because  the 
simple  methods  of  clinical  examination  give  information  which 
is  as  useful  for  practical  purposes  as  that  furnished  by  the  more 
accurate  and  elaborate  procedures. 

The  character  of  the  stools  depends  primarily  on  the  composi- 
tion of  the  food.  It  is  modified  by  the  digestive  powers  of  the 
individual  infant  and  by  the  amount  and  rapidity  of  absorption 
of  the  products  of  digestion.  The  amount  of  absorption  depends 
to  a  considerable  extent  on  the  rapidity  with  which  the  intestinal 
contents  pass  through  the  intestinal  tract.  The  character  of  the 
stools  also  depends  on  the  nature  of  the  bacterial  flora  of  the  in- 
testir.o.  This  is  dependent,  to  a  large  extent,  on  the  nature  of  the 
food.  The  influence  which  the  bacteria  exert  depends  largely  on 
the  digestive  power  of  the  infant  and  the  rapidity  with  which  the 
products  of  digestion  are  absorbed.  The  more  feeble  the  digestive 
power  and  the  slower  the  absorption,  the  greater  the  effect  of  the 
bacteria.  It  is  often  difficult,  therefore,  to  draw  conclusions  from 
the  examination  of  the  stools  as  to  just  what  is  going  on  in  the 
intestines.  It  is  usually  possible,  however,  to  determine  whether 
any  given  food  element  is  properly  digested  and  assimilated  or 
not,  and  in  many  diseased  conditions  to  tell  what  element  is  at 
fault.  The  presence  of  an  improperly  digested  food  element  in 
the  stools  does  not  necessarily  show,  however,  that  this  is  the 
element  primarily  at  fault,  although  it  usually  is.  Fat  curds  may, 
for  example,  be  present  in  the  stools  as  the  result  of  the  fermenta- 
tion of  sugar,  the  excessive  peristalsis  resulting  from  the  irritation 
caused  by  the  products  of  the  fermentation  of  sugar  preventing 
the  proper  absorption  of  the  fat.    When  the  element  at  fault  is 

87 


88  STOOLS  IN  INFANCY 

known,  it  can  be  reduced  and  the  necessary  amount  of  the  reduc- 
tion determined  by  repeated  examination  of  the  stools. 

MECONIUM 

The  meconium  is  dark  brownish-green  in  color.  The  first  me- 
conium passed  is  semi-soUd,  having  been  partially  dried  out  in  the 
large  intestine.  The  remainder  is  more  viscid.  It  is  composed 
of  mucus,  bile,  intestinal  secretions  and  cells,  with  vernix  caseosa, 
epithelial  cells  and  hairs  swallowed  with  the  amniotic  fluid.  The 
meconium  stools  are  replaced  after  from  two  to  four  days  by  stools 
composed  of  bile-tinged  mucoid  intestinal  secretions.  They  are 
usually  dark-green,  but  may  be  dark-brown  or  brownish-yellow, 
according  to  whether  the  bile  pigment  is  in  the  form  of  bihrubin  or 
bihverdin.  The  change  to  the  normal  fecal  stool  occurs  gradually 
during  the  next  two  or  three  days. 

The  stools  of  the  breast-fed  infant  differ  normally  in  their  char- 
acteristics from  those  of  the  infant  fed  on  cow's  milk.  The  addi- 
tion of  starch  to  cow's  milk  changes  the  character  of  the  stools. 
The  appearance  of  the  stools  varies  also  with  the  kind  of  sugar 
which  is  added  to  the  milk. 

THE   STOOLS   OF  BREAST-FED   INFANTS 

During  the  first  few  weeks  or  months  of  life,  the  breast-fed  infant 
has  three  or  four  stools  daily.  These  are  of  about  the  consistency 
of  pea  soup  and  of  a  peculiar  golden-yellow  color.  The  odor  is 
shghtly  sour  or  aromatic,  and  the  reaction  slightly  acid.  The 
number  of  stools  gradually  diminishes  to  two  or  three  in  the  twenty- 
four  hours  and  the  consistency  becomes  more  salve-like.  The  other 
characteristics  are  the  same.  The  golden-yellow  color  is  due  to 
bihrubin,  which,  on  account  of  the  short  time  which  it  remains 
in  the  intestine,  the  relatively  low  protein  content  of  the  milk 
and  the  low  reducing  power  of  the  infant's  intestine,  passes  un- 
changed through  the  intestinal  tract.  The  odor  is  due  to  a  com- 
bination of  lactic  and  fatty  acids.  The  acid  reaction  is  due  to  the 
relative  excess  of  fat  over  protein  in  the  milk. 

It  is  not  uncommon  for  babies,  even  when  they  are  thriving  on 
the  breast,  to  have  a  large  number  of  stools  of  diminished  con- 
sistency and  of  a  brownish  color.  The  examination  of  the  breast- 
milk  in  such  instances  usually  shows  that  the  proteins  are  high. 
It  is  also  not  unusual  to  find  many  soft,  fine  curds,  and  some- 
times mucus  in  the  stools  of  healthy  breast-fed  babies.     Such 


STOOLS  IN  INFANCY  89 

stools  are  undoubtedly  abnormal.  It  is  unwise  to  pay  too  much 
attention  to  them,  however,  if  the  baby  is  gaining  in  weight  and 
appears  well.  The  breast-fed  infant  will  often  go  weeks  or  months 
without  a  normal  stool  and  yet  thrive  perfectly,  while  if  a  baby 
had  such  stools  when  it  was  taking  cow's  milk  it  would  not  thrive 
and  would  show  distinct  evidences  of  malnutrition.  It  is,  there- 
fore, not  only  unnecessary,  but  distinctly  wrong,  to  wean  a  baby 
simply  because  the  stools  are  abnormal,  if  it  is  doing  well  in  other 
ways. 

THE   STOOLS   OF   INFANTS   FED   ON   COW's  MILK 

Infants  that  are  thriving  on  cow's  milk  mixtures  have,  as  a  gen- 
eral rule,  fewer  movements  in  the  twenty-four  hours  than  do  breast- 
fed babies,  and  these  movements  are  firmer  in  consistency.  SUght 
constipation  is  not  uncommon  after  the  first  months  and  is  not 
pathological.  The  color  of  the  stools  is  a  lighter  yellow.  This  is 
probably  due  in  part  to  the  relatively  larger  amount  of  protein  and 
in  part  to  the  fact  that  some  of  the  bilirubin  is  converted  into  hydro- 
bilirubin.  When  the  relative  proportions  of  fat  and  protein  in  the 
mixtures  are  approximately  the  same  as  they  are  in  breast  milk 
the  odor  and  reaction  of  the  stools  are  essentially  the  same  as  when 
the  baby  is  taking  breast  milk.  When  infants  are  given  whole 
cow's  milk  or  simple  dilutions  of  cow's  milk,  so  that  the  percentage 
of  protein  is  about  the  same  as  that  of  the  fat,  the  odor  is  sUghtly 
modified  toward  the  fecal  or  cheesy,  because  of  the  action  of  bac- 
teria on  the  casein.  The  reaction  becomes  alkaline  for  the  same 
reason. 

Skimmed  Milk  Mixtures. — ^When  infants  are  fed  on  skimmed 
milk  or  on  mixtures  containing  very  small  percentages  of  fat  and 
high  percentages  of  protein,  the  stools  have  a  sUghtly  brownish- 
yellow  color,  a  sUghtly  cheesy  or  foul  odor  and  a  strongly  alkaline 
reaction,  because  of  the  longer  stay  of  the  casein  in  the  intestine 
and  the  consequently  greater  opportunity  for  bacterial  action  and 
for  the  change  of  bilirubin  into  hydrobihrubin.  In  most  instances 
the  stools  have,  when  spread  out,  a  peculiar,  smooth,  salve-like 
appearance  like  those  from  buttermilk. 

Whey  and  Whey  Mixtures. — ^When  infants  are  fed  on  whey 
or  whey  mixtures  low  in  fat,  the  stools  have  essentially  the  same 
characteristics  as  those  from  skimmed  milk,  except  that  they  are 
usually  browner.  Whey  has  a  laxative  action  in  many  instances 
and  sometimes  has  to  be  given  up  on  this  account. 

Starch  Mixtures. — ^When  starch  is  added  to  cow's  milk  mix- 
tures the  color  of  the  stools  becomes  more  distinctly  brownish  and 


m  STOOLS  IN  INFANCY 

the  reaction  tends  toward  the  acid.  The  odor  is  more  aromatic. 
The  source  from  which  the  starch  is  derived  apparently  has  but 
little  effect  on  the  number  of  stools,  although  it  is  commonly 
thought  that  barley  starch  is  constipating  and  oatmeal  starch 
laxative.  The  action,  if  there  is  any,  seems  to  vary  with  the  in- 
dividual infant.  It  must  not  be  forgotten  in  this  connection  that 
most  starch  flours  contain  small  brownish  specks  which  are  the 
remains  of  the  husks  (cellulose).  These  specks  pass  through  the 
gastrointestinal  tract  unaffected  and  appear  in  the  stools.  They 
are  sometimes  mistaken  for  intestinal  sand  or  for  dirt. 

Dextrin-Maltose  Mixtures. — The  addition  of  the  various  com- 
binations of  the  dextrins  and  maltose  to  cow's  milk  mixtures 
changes  the  color  of  the  stools  to  a  distinct  brown,  tends  to  make 
the  reaction  acid  and  to  increase  the  acidity  of  the  odor.  These 
sugars  usually  have  a  laxative  influence  but  sometimes  constipate. 
In  general,  the  higher  the  proportion  of  maltose,  the  greater  is  the 
laxative  action.  When  these  combinations  of  the  dextrins  and 
maltose,  or  the  malted  foods,  which  amount  to  the  same  thing, 
are  given  without  milk,  the  stools  are  dark-brown,  sticky,  acrid 
in  odor  and  acid  in  reaction. 

Buttermilk  and  Buttermilk  Mixtures. — The  stools  of  infants 
fed  on  buttermilk  and  buttermilk  mixtures  are  of  a  peculiar 
shiny,  salve-like  appearance,  grayish-brown  or  olive-green  in 
color,  alkaline  in  reaction  and  have  a  very  characteristic  acrid 
odor. 

Animal  Food. — ^When  beef  juice  or  broth  is  added  to  the  in- 
fant's diet  the  color  of  the  stools  is  changed  to  brown,  while  the 
odor  becomes  fecal  and  the  reaction  alkaline  from  the  action  of 
bacteria  on  the  proteins.  It  is  not  uncommon  when  babies  are 
taking  beef  juice  to  have  one  portion  of  the  stool  brown  with 
the  remainder  yellow,  the  dividing  line  between  the  two  colors 
being  very  distinct.  The  dark  color  represents,  of  course,  the  meal 
at  which  the  beef  juice  was  taken. 

THE  STAEVATION  STOOL 

The  starvation  stool  is  composed  of  bile,  the  intestinal  secre- 
tions and  bacteria.  It  resembles  the  meconium  in  appearance. 
It  is  small,  and  brownish  or  brownish-green  in  color.  It  is  some- 
times constipated,  sometimes  loose.  It  usually  has  a  stale  odor 
like  that  of  starch  or  paste.  In  some  cases  it  has  the  odor  of 
acetic  acid  as  the  result  of  action  of  microorganisms.  It  not  in- 
frequently contains  bile-stained  mucus. 


STOOLS  IN  INFANCY  91 

REACTION   OP  THE   STOOLS 

The  reaction  of  the  normal  stool  depends  on  the  relation  be- 
tween the  fat  and  protein  in  the  food.  When  there  is  a  relative 
excess  of  fat  the  reaction  is  acid;  when  there  is  a  relative  excess 
of  protein  the  reaction  is  alkaline,  the  reaction  depending,  in  the 
one  case,  on  the  products  of  the  decomposition  of  fat,  in  the  other 
on  the  products  of  the  decomposition  of  protein.  The  carbo- 
hydrates have  but  httle  effect  on  the  reaction  of  the  normal  stool. 
When  the  carbohydrates  are  in  excess,  or  when  there  is  fermenta- 
tion of  the  carbohydrates  as  the  result  of  bacterial  action,  the 
acidity  of  the  stools  is  markedly  increased.  Stools  which  irritate 
the  buttocks  are  invariably  acid  in  reaction  and  in  many  instances 
this  excessive  acidity  is  due  to  the  fermentation  of  carbohydrates. 
Frothy  stools  are  usually  acid  in  reaction  and  the  result  of  the 
fermentation  of  carbohydrates.  Sometimes,  however,  the  frothi- 
ness  is  caused  by  gases  formed  during  the  decomposition  of  pro- 
tein. The  reaction  of  the  stools  is  best  tested  by  placing  wet 
red  or  blue  litmus  paper  on  a  fresh  surface  of  the  stool.  It  is,  how- 
ever, except  when  there  is  excessive  acidity,  of  comparatively 
little  importance  clinically. 

ODOR   OF  THE   STOOLS 

The  odor  of  the  stools  depends  on  the  composition  of  the  food, 
the  rapidity  of  the  absorption  of  the  products  of  digestion  and  the 
degree  of  the  bacterial  activity.  The  fats  give  the  odor  of  butyric 
or  lactic  acid  to  the  stools.  The  carbohydrates,  if  thoroughly 
utiUzed,  do  not  affect  the  odor;  if  not  utilized,  they  give  the  odors 
of  lactic,  acetic  or  succinic  acids.  The  proteins  give  cheesy  odors 
of  various  sorts,  sometimes  those  of  skatol,  indol  and  phenol. 

The  odor  of  the  normal  stool  and  the  influence  of  variations 
in  the  diet  upon  it  have  already  been  mentioned.  The  stools  of 
fat  indigestion  may  have  a  strong  odor  of  butyric  acid,  those  of 
protein  indigestion  various  cheesy  or  putrefactive  odors  as  the 
result  of  the  decomposition  of  the  protein  by  bacteria.  When 
several  elements  of  the  food  are  improperly  digested  the  odor  is  a 
combination  of  those  resulting  from  the  decomposition  of  the  va- 
rious elements.  The  stools  of  cholera  infantum  are  almost  odorless. 
Stools  composed  almost  entirely  of  mucus  have  a  peculiar  aromatic 
odor  resembling  that  of  wet  hay.  When  there  are  deep  ulcerative 
or  gangrenous  processes  in  the  intestine,  the  stools  have  a  putrefac- 
tive or  gangrenous  odor. 


92  STOOLS  IN  INFANCY 

COLOR   OF   THE   STOOLS 

The  normal  variations  in  the  color  of  the  stools  according  to 
the  composition  of  the  food  have  already  been  mentioned.  Ab- 
normalities in  the  color  are  very  common.  The  color  of  the  stool 
must  not  be  judged  from  the  outside,  as  it  may  change  very 
rapidly  as  the  result  of  drying  and  exposure  to  the  air.  The  stool 
must  be  broken  up  or  smoothed  out  and  the  inside  examined. 

Green. — The  most  common  abnormal  color  is  green.  The  shade 
of  green  may  vary  from  a  very  deUcate  Ught  grass-green  to  a 
dark  spinach-green.  In  a  general  way,  the  darker  the  green,  the 
greater  its  significance.  When  a  stool  is  otherwise  normal,  a  very 
Ught  grass-green  color  is  of  no  practical  importance.  The  change 
from  yellow  to  green  after  the  stool  is  passed  is  .not  abnormal. 
The  green  color  is,  in  the  vast  majority  of  instances,  due  to  the 
change  of  bihrubin  to  biliverdin.  There  is  much  doubt  as  to  the 
cause  of  this  change.  It  is  probable  that  it  may  be  due  to  either 
excessive  acidity  or  alkalinity  of  the  intestinal  contents  or  to  the 
presence  of  some  oxidizing  ferment.  The  green  color  is  not  charac- 
teristic of  any  special  type  of  disease.  In  some  instances  it  is  due 
to  the  action  of  the  bacillus  pyocyaneus.  If  it  is  due  to  bacterial 
action,  the  addition  of  nitric  acid  decolorizes  the  stool.  If  it  is 
due  to  biliverdin,  the  addition  of  nitric  acid  gives  the  characteristic 
colors  of  Gmelin's  test. 

Gray. — ^The  next  most  common  abnormal  color  is  gray.  This 
is  due,  as  a  rule,  to  the  absence  of  bile  and  the  presence  of  some 
form  of  fat,  usually  soap,  in  the  stool.  It  must  be  remembered, 
however,  that  there  may  be  bile  in  the  stool  even  when  it  is  gray, 
the  bile  pigment  being  in  the  form  of  the  colorless  leucohydrobili- 
rubin.  It  is  never  safe,  therefore,  to  conclude  that  there  is  no  bile 
in  the  stool  without  a  chemical  examination.  The  easiest  and  most 
satisfactory  test  is  that  with  corrosive  sublimate.  This  test  is, 
however,  not  always  accurate.  When  the  stools  are  gray  at  birth 
or  become  so  within  a  few  days  after  birth,  the  lesion  is  usually  a 
congenital  obUteration  of  the  bile  ducts.  It  may  be,  however,  an 
atresia  of,  or  an  obstruction  in,  the  intestine.  When  the  gray  color 
appears  later,  and  especially  when  it  is  associated  with  the  pres- 
ence of  large  amounts  of  mucus,  the  trouble  is  usually  in  the 
duodenum. 

White. — ^White  stools  are  composed  chiefly  of  unabsorbed  fat 
in  the  form  of  soaps.  The  white  stools  may  be  soft,  looking  like 
curdled  milk  or,  more  often,  hard  and  dry,  resembling  the  stools  of 
a  dog  which  has  been  eating  bones. 


STOOLS  IN  INFANCY  93 

Black. — The  black  stool,  while  in  rare  instances  due  to  the 
presence  of  changed  blood,  is  usually  due  to  the  action  of  some 
drug.  This  drug  is  ordinarily  bismuth,  but  sometimes  iron  or 
charcoal.  In  this  connection  it  is  well  to  remember  that,  when 
there  is  no  sulphureted  hydrogen  in  the  intestine,  bismuth  may 
pass  through  the  intestinal  tract  without  being  changed  in  color 
The  administration  of  a  grain  or  two  of  sulphur  in  the  twenty- 
four  hours  will  turn  the  stools  black.  Whether  this  is  of  any  ad- 
vantage or  not  is  questionable. 

Blue. — The  stools  are  sometimes  of  a  slaty-blue  color.  This 
color  is  due  to  some  change  in  the  bile  pigments  and  is  of  no  more 
significance  than  the  green  color. 

Pink. — It  is  very  common  to  see  a  pink  stain  on  the  diapers 
about  a  stool  which  is  otherwise  normal  or  nearly  so.  This  pink 
stain  is  of  no  especial  significance  and  is  due  to  some  unknown 
change  in  the  bile  pigment. 

ABNORMAL   CONSTITUENTS 

Curds. — ^The  most  conmion  abnormal  constituents  of  the  stools 
are  curds.  There  are  two  kinds  of  curds,  one  primarily  composed 
of  casein,  the  other  composed  mainly  of  fat,  mostly  in  the  form  of 
fatty  acids  and  soaps.  The  small  amount  of  fat  in  the  casein 
curds  and  the  small  amount  of  protein  in  the  fat  curds  are  merely 
incidents.  The  casein  curds  vary  in  size  from  that  of  a  bean  to 
that  of  a  pecan  nut.  They  are  usually  white,  sometimes  yellow  in 
color.  They  are  firm  and  tough,  cannot  be  broken  up  by  pressure, 
and  sink  in  water.  When  placed  in  formalin  they  become  as  hard 
as  rocks.  They  are  insoluble  in  ether.  The  fat  curds  are  small, 
varying  in  size  from  that  of  a  pinhead  to  that  of  a  small  pea.  They 
vary  in  color  from  white  to  yellow  or  green,  according  to  the  gen- 
eral color  of  the  movement.  They  are  easily  broken  up  by  pres- 
sure and  when  shaken  up  in  water  tend  to  remain  in  suspension. 
They  are  soluble  in  ether  to  a  considerable  extent  after  acidifica- 
tion and  heating,  and  are  imafifected  by  formalin. 

Mucus. — Mucus  can  be  detected  in  small  amounts  under  the 
microscope  in  the  majority  of  normal  stools  and  is  almost  invari- 
ably present  in  abnormal  stools.  It  is  never  present  macroscopic- 
ally  in  normal  stools,  but  is  very  often  visible  in  the  abnormal. 
It  does  not  denote  any  special  form  of  disease,  but  merely  an  ex- 
cessive secretion  of  the  mucous  glands  of  the  intestine  as  the  result 
of  some  irritation.  When  it  is  thoroughly  mixed  with  the  feces 
it  usually  comes  from  the  small  intestine;  when  in  combination 


94  STOOLS  IN  INFANCY 

with  a  clay-colored  stool,  from  the  duodenum;  when  on  the  out- 
side of  a  constipated  stool,  from  the  rectum.  Stools  composed 
mostly  or  entirely  of  mucus  and  blood  indicate  either  severe  in- 
flammation of  the  colon  or  intussusception.  Undigested  starch  is 
often  mistaken  for  mucus.  It  can  be  distinguished  by  the  addi- 
tion of  some  preparation  of  iodine,  which  stains  starch  blue  but 
does  not  affect  the  mucus.  The  suspected  material  should  be 
taken  off  of  the  diaper  in  order  to  avoid  possible  confusion  because 
of  the  presence  of  starch  on  the  diaper.  It  is  of  importance  not 
to  use  too  strong  a  solution  of  iodine. 

Blood. — Blood  on  the  outside  of  a  constipated  stool  indicates 
a  crack  of  the  anus.  Blood  mixed  with  mucus  indicates  either 
severe  inflammation  of  the  large  intestine  or  intussusception. 
Blood  in  infancy  is  seldom  due  to  hemorrhoids.  In  rare  instances 
the  hemorrhage  may  come  from  an  intestinal  polyp.  Hemorrhage 
from  the  bowel  in  the  first  few  days  of  life  is  ordinarily  a  symptom 
of  hemorrhagic  disease  of  the  new-born. 

Pus. — Pus  indicates  severe  inflanrnaation  of  the  large  intestine. 
It  is  usually  not  present  early  in  the  disease,  but  appears  later. 
When  the  infants  survive  the  acute  stage  it  persists  into  convales- 
cence. Pus  can  be  found  with  the  microscope  in  nearly  every  case 
of  inflammation  of  the  colon,  but  is  of  no  special  significance  un- 
less visible  macroscopically. 

Membrane. — Membrane  indicates  very  severe  infiammation  of 
the  large  intestine  and  is  rarely  seen,  the  patients  usually  dying 
before  membrane  appears  in  the  stools. 

Other  abnormal  constituents  are  undigested  masses  of  food, 
foreign  bodies  which  have  been  swallowed,  and  worms. 

MICROSCOPIC  EXAMINATION   OF  THE   STOOLS 

The  macroscopic  examination  of  the  stools  affords  data  suffi- 
ciently refiable  for  clinical  work  in  the  great  majority  of  instances. 
It  may,  however,  lead  to  erroneous  conclusions,  especially  with 
regard  to  the  amoimt  of  fat  and  undigested  starch.  Fatty  and 
starchy  stools  sometimes  appear  perfectly  normal  macroscopically, 
and  microscopic  examination  will  alone  prevent  mistakes.  It  is 
advisable,  therefore,  in  all  but  the  plainest  cases,  to  examine  the 
stools  microscopically  as  well  as  macroscopically.  The  microscopic 
examination  of  the  stools  is  not  a  difficult  procedure,  and  can  be 
carried  out  in  ten  minutes  or  less  by  anyone  accustomed  to  it. 
Controls  of  the  microscopic  examination  by  chemical  examination 
of  the  stools  have  shown  that  it  gives  results  sufficiently  reliable 


STOOLS  IN  INFANCY  95 

for  clinical  purposes.  A  certain  amount  of  experience  is  necessary, 
however,  in  order  to  recognize  the  variations  in  the  microscopic 
picture.  The  stools  normally  show  a  certain  amount  of  fat  in 
some  form  or  other,  but  never  show  undigested  starch.  The  chief 
difficulty  in  the  microscopic  examination  is  to  learn  to  recognize 
the  normal  variations  in  the  amount  of  fat. 

The  feces,  if  hard,  are  first  rubbed  up  with  a  little  water.  It  is 
important  not  to  dilute  them  too  much.  If  not  hard,  they  are 
thoroughly  mixed.  A  small  portion  is  then  spread  out  very  thin 
on  a  sHde  under  a  cover-glass  and  examined  for  the  presence  of  un- 
digested tissues  or  pathological  elements,  such  as  blood,  pus  and 
eggs  of  parasites. 

The  second  portion  is  stained  with  Lugol's  solution  (iodine  2, 
potassium  iodide  4,  distilled  water  100),  or  Gram's  solution, 
(iodine  1,  potassium  iodide  2,  distilled  water  300),  and  examined 
for  starch.  The  starch  granules  stain  blue  or  violet.  Certain 
microbes  also  stain  blue.  These,  the  so-called  iodophilic  bacteria, 
are  associated  with  faulty  carbohydrate  digestion,  and,  when 
found  alone  without  other  symptoms,  are  suggestive  of  a  begin- 
ning disturbance  in  the  digestion  of  the  carbohydrates.  Before 
concluding  that  undigested  starch  is  present,  all  possibility  of 
contamination  with  baby  powders  must  be  eliminated.  A  diag- 
nosis of  starch  indigestion  should  never  be  made  unless  the  char- 
acteristic form  of  the  starch  granules  is  made  out.  Negative 
microscopic  findings,  however,  do  not  absolutely  exclude  the 
presence  of  starch  from  the  stools.  De  Just  and  Constant  ^ 
showed  that  small  amounts  of  starch  could  be  detected  even 
when  it  was  not  visible  under  the  microscope. 

A  third  portion,  undiluted  with  water,  is  stained  with  a  saturated 
alcoholic  solution  of  Sudan  III.  The  neutral  fat  drops  and  fatty 
acid  crystals  stain  red.  Soap  crystals  do  not  stain  with  Sudan  III. 
After  this  specimen  is  examined  and  the  microscopic  picture  is 
clear,  a  drop  of  glacial  acetic  acid  is  allowed  to  run  under  the  cover- 
glass,  is  thoroughly  mixed  in,  and  then  heated  until  it  begins  to 
simmer.  It  should  not  be  boiled,  because,  if  it  is,  the  fat  is  Hkely 
to  be  driven  to  the  edge  of  the  cover-glass  and  lost.  This  pro- 
cedure converts  the  soap  into  fatty  acids  which  appear  as  large 
stained  drops.  They  crystallize  upon  cooling.  They  usually  re- 
tain the  red  stain.  Any  increase  in  the  amount  of  fat  after  the 
addition  of  acetic  acid  indicates  the  presence  of  a  corresponding 
amount  of  soaps. 

1  De  Just  and  Constant:  Bull.  Sci.  Pharmacolog.,  1913,  xz,  707;  idem.,  1914, 
xxi,  28. 


96  STOOLS  IN  INFANCY 

This  method  of  staining,  while  it  enables  us  to  distinguish  be- 
tween the  amount  of  neutral  fat  and  fatty  acids  together,  on  the 
one  hand,  and  of  soaps,  on  the  other  hand,  does  not  make  it  possi- 
ble to  determine  how  much  of  the  fat  is  in  the  form  of  neutral  fat. 
This  point  can  be  determined  by  the  use  of  carbol-fuchsin.  The 
stain  may  be  prepared  as  it  is  for  staining  tubercle  bacilli.  This 
may  be  too  strong,  however,  and,  if  so,  the  solution  should  be 
diluted  with  an  equal  amount  of  95%  alcohol.  Carbol-fuchsin 
does  not  stain  neutral  fat,  but  stains  fatty  acids  a  brilliant  red 
and  soaps  a  dull  red.  The  following  table  shows  the  difference  in 
the  staining  properties  of  neutral  fat,  fatty  acids  and  soaps. 

TABLE   17 


Stain 

Neviral  fat 

Fatty  adds 

Soaps 

Sudan  III 

Diluted  carbol- 
fuchsin 

Drops  staining 
orange  red 

Drops  do  not 
stain 

Drops  staining  red, 
or  crystals  stain- 
ing orange-red 

Drops  and  crystals 
stain  brilliant  red 

Crystals  do  not 
stain 

Crystals  stain  dull 
red 

It  is  possible,  therefore,  by  using  these  two  stains  in  conjunction, 
to  determine  accurately  enough  for  chnical  purposes  the  relative 
proportions  of  neutral  fat,  fatty  acids  and  soaps  in  the  stool.  An 
excess  of  neutral  fat  indicates  that  the  digestion  of  fat  is  not  carried 
on  normally;  an  excess  of  fatty  acids  and  soaps,  that  the  digestion 
is  normal  but  absorption  is  abnormal.  It  must  be  remembered  in 
interpreting  the  importance  of  an  excess  of  fat  in  the  stool,  that 
the  younger  the  baby,  the  less  is  the  significance  of  an  excess  of  fat 
and  vice  versa. 

Laws  and  Bloor  *  have  recently  developed  a  method  by  which 
the  amount  of  fat  in  a  stool  may  be  accurately  determined  in 
about  one  hour.  This  method,  however,  requires  a  well-equipped 
laboratory  and  considerable  knowledge  of  chemistry. 

It  is  well  to  examine  the  specimen  first  with  a  low-power  objec- 
tive and  later  with  a  high-power  in  order  to  bring  out  the  detailed 
structure. 


THE  BACTERIOLOGIC  EXAMINATION  OF  THE   STOOLS 

Our  knowledge  of  the  bacteriology  of  the  disturbances  of  diges- 
tion and  of  the  various  inflammatory  diseases  of  the  intestine  is  so 

*  Laws  and  Bloor:  Am.  Jour.  Dis.  Ch.,  1916,  xi,  229. 


STOOLS  IN  INFANCY  97 

limited  at  present  that  no  conclusion  of  clinical  importance  can  be 
drawn  from  the  microscopic  examination  of  the  stools,  the  only  ex- 
ception being  possibly  the  presence  of  large  numbers  of  iodophilic 
bacteria,  which,  as  already  stated,  point  to  disturbance  of  the 
digestion  of  the  carbohydrates.  In  general,  Gram-positive  bacteria 
will  predominate  in  an  acid  and  Gram-n^ative  in  an  alkaline 
stool.  The  determining  factors  are  the  same  as  those  which  cause 
the  reaction  of  the  stool. 

STOOLS   OF  DIFFERENT  TYPES   OF  INDIGESTION 

The  characteristics  of  the  stools  in  some  of  the  more  marked 
types  of  indigestion  are  fairly  definite.  They  are  summarized  be- 
low. 

The  Stools  of  Fat  Indigestion. — Undigested  fat  may  show  it- 
self in  the  stools  in  the  form  of  small,  soft  curds,  by  giving  a  greasy, 
shiny  appearance  to  the  stool  or  by  giving  it  a  gray  or  white  color. 
The  small  curds  are,  of  course,  easily  recognized.  Sometimes  the 
stools  have  an  oily  appearance  and  the  color  is  that  of  Indian  meal. 
The  presence  of  undigested  fat  may  be  shown  roughly  by  rubbing 
some  of  the  stool  on  a  piece  of  smooth,  soft  paper.  If  there  is  an 
excess  of  fat,  the  paper  will  have,  when  dry,  the  appearance  of 
oiled  paper.  When  there  is  an  excess  of  neutral  fat,  the  stools  are 
often  of  a  creamy  consistency.  If  the  fat  is  largely  in  the  form  of 
soaps,  the  stools  are  usually  clay-colored  or  very  dry  and  crumbly. 
The  reaction  is  highly  acid.  The  odor  is  rancid,  like  that  of 
butyric  acid.  Microscopically,  these  stools  show  a  large  excess  of 
fat  in  various  forms. 

The  Stools  of  Carbohydrate  Indigestion. — The  character  of  the 
stools  of  carbohydrate  indigestion  depends  on  whether  the  dis- 
turbance is  in  the  digestion  of  starch  alone  without  bacterial 
action  or  in  the  digestion  of  either  or  both  starch  and  sugar  with 
bacterial  fermentation.  When  the  disturbance  is  solely  in  the 
digestion  of  starch  and  the  bacterial  fermentation  is  not  marked, 
the  stools  are  brown  or  golden-yellow  in  color  and  salve-like  in 
consistency.  They  may,  as  already  stated,  appear  macroscopically 
normal.  In  rare  instances  they  are  very  dry  and  brittle.  The 
reaction  is  acid.  The  odor  is  acid,  the  character  of  the  odor  depend- 
ing on  the  form  of  acid  present.  The  iodine  test  will  often  show  the 
presence  of  undigested  starch  macroscopically.  Microscopically 
these  stools  show  undigested  starch  by  the  iodine  test,  and  an 
excess  of  iodophilic  bacteria. 

When  bacterial  fermentation  is  added  to  the  disturbance  of 


98  STOOLS  IN  INFANCY 

digestion  of  either  starch  or  sugar,  the  stools  are  loose,  green  and 
frothy.  The  reaction  is  acid  from  the  presence  of  lactic,  acetic  or 
succinic  acid.  The  odor  is  acid,  the  character  of  the  odor  depend- 
ing on  the  form  of  acid  present.  These  stools  often  cause  excoria- 
tion of  the  buttocks  and  genitals. 

The  Stools  of  Protein  Indlgestioii. — The  presence  of  large, 
tough  curds  in  the  stools  is,  of  course,  evidence  of  protein  or  rather 
casein  indigestion.  In  general,  however,  the  stools  of  protein  in- 
digestion are  loose,  brownish  in  color,  alkaUne  in  reaction  and 
with  a  foul  odor,  the  odor  in  some  instances  being  fecal,  in  others 
cheesy,  in  others  a  combination  of  the  two. 

Mixed  Forms  of  Indigestion. — Mixed  types  of  stools  as  the 
result  of  mixed  types  of  indigestion  modified  by  bacterial  fermenta- 
tion and  decomposition  are  far  more  common  than  the  pure  types 
alone  and  are  often  very  difficult  to  interpret. 

The  examination  of  the  stools  gives  information  regarding  the 
digestive  processes  which  cannot  be  obtained  in  any  other  way. 
Without  such  examination  the  treatment  of  disturbances  of  diges- 
tion is  always  unscientific  and  often  irrational.  The  macroscopic 
examination  of  the  stools  affords  information  of  the  greatest  im- 
portance, but  in  many  instances  will  lead  to  error  unless  the 
microscopic  examination  is  also  made.  The  microscopic  examina- 
tion is  a  simple  one  and  requires  but  little  time.  The  results  ob- 
tained from  it  are,  for  practical  purposes,  as  rehable  as  those  ob- 
tained from  the  chemical  examination.  The  stools  should  be 
examined  both  macroscopically  and  microscopically  in  every  dis- 
turbance of  the  digestion  in  infancy. 


SECTION  n 
BREAST  FEEDING 

CHAPTER  IX 

GENERAL  CONSIDERATIONS 

It  is  generally  recognized  that  the  natural  food  for  the  human 
infant  is  human  milk,  that  breast-fed  babies  are  more  likely  to  Uve 
than  the  artificially-fed  and  that,  as  a  class,  they  are  healthier, 
more  vigorous  and  more  resistant.  Few  appreciate,  however,  how 
much  greater  the  mortality  is  in  the  artificially-fed  than  in  the 
breast-fed.  There  are  many  statistics  to  prove  this  fact.  It  is 
hardly  necessary,  however,  to  give  more  than  a  few  of  them. 

Mortality. — In  Berlin,  where  the  character  of  the  feeding  of 
all  Hving  children  is  determined  by  the  census,  during  the  five 
years,  1900  to  1904,  only  9%  of  the  infantile  deaths  were  in  breast- 
fed babies.^  The  Department  of  Health  of  New  York  City  esti- 
mates that  over  85%  of  all  infantile  deaths  are  in  those  artificially 
fed.^  Davis  ^  found  that  in  Boston,  in  1911,  74%  of  the  deaths  of 
infants  over  two  weeks  of  age  were  in  the  artificially-fed,  and 
calculates  that  in  Boston  the  bottle-fed  is  six  times  as  Ukely  to  die 
as  the  breast-fed  infant.  LuUng,'*  in  a  study  of  13,952  children 
bom  in  Baudeloque's  clinic,  found  an  infant  mortality  of  14%  in 
the  breast-fed,  31%  in  those  who  were  bottle-fed  by  their  own 
mothers,  and  50%  ia  those  who  were  bottle-fed  by  strangers. 
Armstrong,^  in  a  study  of  1,000  infants  in  Liverpool,  in  1903, 
found  that  8.4%  of  the  breast-fed  babies  died  in  the  first  year 
against  22.8%  of  the  artificially-fed.  Of  1,000  fatal  cases  of 
diarrheal  disease  investigated  by  the  Health  Department  of  the 
City  of  New  York,  in  1908,  only  90  had  previously  been  entirely 
breast-fed.^  Further  evidence  of  the  effect  of  breast  feeding  on  the 
infant  mortahty  is  the  fact  that  during  the  Siege  of  Paris,  1870-71, 

» Graham:  Journal  A.  M.  A.,  1908,  li,  1045. 

«Holt:  Journal  A.  M.  A.,  1910,  Uv,  682. 

•  Davis:  Amer.  Jour.  Diseases  of  Children,  1913,  v,  234. 

*Luling:  Th^  de  Paris,  1900. 

'Armstrong:  British  Join:.  Children's  Diseases,  1904,  i,  115. 

99 


100  BREAST  FEEDING 

while  the  general  mortality  rate  doubled,  the  infant  mortality  rate 
fell  from  330  to  170  per  thousand  deaths,  the  reason  being  that  the 
women,  having  no  other  food  to  give  their  babies,  had  to  nurse 
them.^ 

Relative  Frequency  of  Breast  Feeding. — The  relative  fre- 
quency of  breast  feeding  varies  in  diffierent  countries  and  in  differ- 
ent races.  In  Japan,  breast  feeding  is  the  rule.  In  Greenland,  and 
among  the  Eskimos,  artificial  feeding  is  practically  unknown.  The 
proportion  of  breast-fed  babies  is  much  smaller  in  other  countries. 
Nordheim,^  for  example,  found,  as  the  other  extreme,  that  only 
3.6%  of  1,000  women  coming  to  the  Women's  Dispensary  in 
Munich,  nursed  their  babies  longer  than  three  months.  Davis,' 
from  an  investigation  made  in  1911,  estimated  that  68%  of  all 
Boston  babies  between  the  ages  of  two  weeks  and  one  year  were 
breast-fed,  while  the  Board  of  Health  of  the  City  of  New  York 
estimates  that  about  85%  of  the  infants  in  New  York  are  breast- 
fed.^ Holt,^  however,  thinks  that,  as  these  data  were  gathered 
largely  from  the  tenement  district  statistics,  they  are  too  high, 
and  that  80%  is  nearer  the  truth  for  the  entire  population.  Kop- 
lik  ^  found  that  10%  of  1,007  infants,  seen  in  private  practice 
in  New  York  City,  were  exclusively  breast-fed,  30%  exclusively 
bottle-fed  and  60%  breast  and  bottle-fed.  Forty  per  cent  of  these 
were  weaned  before  the  fourth  month. 

Ability  of  Women  to  Nurse  Their  Babies. — There  are  two  rea- 
sons why  women  do  not  nurse  their  babies.  They  are  either  unable 
or  unwilling.  There  is  much  difference  of  opinion  as  to  what 
proportion  of  women  are  really  able  to  nurse  their  babies,  although 
it  is  generally  conceded  that  a  large  proportion  of  those  who  do  not 
nurse  their  babies  could  nurse  them,  if  they  thought  they  could  or 
were  compelled  to  do  so.  Nordheim  ^  found  that  of  1,000  women 
642  had  never  nursed,  and  that  86.7%  of  these  had  no  good  reason 
for  not  nursing.  Dluski  ®  found  that  99%  of  the  women  in  the 
Maternity  Department  of  Professor  Pinard,  in  Paris,  were  able  to 
nurse  their  babies.  Holt  ^  estimates,  however,  that  not  over  25% 
of  the  well-to-do  and  cultured  women  of  New  York  City  are  able 
to  nurse  their  babies  over  three  months. 

There  is  no  doubt  that  a  far  larger  proportion  of  women  can 

*  Brehmer:  Wochenschr.  f.  Sauglingsfiirsorge.,  1907,  209. 
"Nordheim:  Archiv.  f.  Kinderheilk.,  1901,  xxxi,  89. 

'  Davis:  Amer.  Jour.  Diseases  of  Children,  1913,  v,  234. 

*  Holt:  Journal  A.  M.  A.,  1908,  U,  1045. 

s  Koplik:  Journal  A.  M.  A.,  1912,  Iviii,  75. 
«  Dluski:  Th^se  de  Paris,  1894. 


BREAST  FEEDING  101 

nurse  their  babies  than  was  formerly  supposed.  Martin  ^  found 
that  in  Wiirtemberg,  where  formerly  only  41%  of  the  women  in  the 
clinics  nursed  their  babies,  100%  are  now  capable.  Constant 
instruction  at  the  Consultations  des  Nourrissons,  in  France,  has 
increased  the  number  of  cases  of  maternal  feeding  among  the 
poor  by  20%  or  30%.  The  experience  at  similar  institutions  in  this 
country  has  been  the  same.  There  is  a  general  belief,  moreover, 
although  there  are  no  figures  to  prove  it,  that  the  ability  of  women 
in  the  wealthier  and  more  highly  educated  classes  in  this  country 
to  nurse  is  steadily  increasing. 

Unwillingness  to  Nurse. — The  main  reason  why  women  do  not 
nurse  their  babies  is  that  they  do  not  appreciate  its  importance. 
This  is  due  to  a  considerable  extent  to  the  fact  that  they  do  not 
receive  proper  advice  from  doctors,  nurses  and  midwives,  who, 
unfortunately,  are  themselves  in  many  instances  ignorant  of  the 
importance  of  breast  feeding.  The  unwillingness  to  nurse  among 
the  wealthier  and  fashionable  classes  is  in  part  because  they  are 
unwilling  to  sacrifice  their  own  pleasure  and  convenience,  in  part 
because  it  is  not  fashionable  in  certain  circles  to  nurse,  and  in  part 
because  of  the  opposition  of  their  husbands,  who  do  not  wish  to  be 
deprived  of  their  wives'  society.  Many  of  them  feel,  moreover, 
that  on  account  of  the  great  improvement  in  artificial  feeding, 
their  babies  will  do  well  enough,  even  if  they  do  not  nurse  them. 
The  unwillingness  of  women  among  the  poorer  classes  to  nurse 
their  babies  is,  in  many  instances,  due  to  the  fact  that  on  account 
of  poverty  they  are  obliged  to  go  to  work.  Ignorance  of  the  ad- 
vantage of  breast  feeding  plays  a  greater  part  in  their  unwilling- 
ness to  nurse  than  among  the  better  educated,  as  do  also  the 
advertisements  of  proprietary  foods. 

Contraindications  to  Breast  Feeding. — A  woman  with  active 
pulmonary  tuberculosis  should  not  nurse  her  baby,  because  of  the 
great  danger  of  infection  of  the  baby.  It  is  usually  inadvisable 
for  a  woman  with  healed  tuberculosis,  pulmonary  or  otherwise,  or 
with  closed  tuberculosis,  to  nurse  her  baby,  because  of  the  danger  of 
starting  up  or  increasing  the  activity  of  the  process.  Although 
tubercle  bacilli  are  sometimes  present  in  the  milk  of  tuberculous 
women,  the  danger  of  infection  from  this  cause  is  negligible. 
Syphilis  is  not  a  contraindication  to  nursing  because,  if  the  mother 
has  active  syphilis  the  baby  has  been  infected  before  birth,  and  if 
the  baby  has  syphilis,  the  mother  always  has  it.  Insanity  is  a 
contraindication  to  nursing  as  is,  in  most  instances,  epilepsy.  Very 
delicate  or  feeble  women  and  women  suffering  from  serious  chronic 
1  Martin:  Archiv.  f.  Gyn.,  1905,  Ixxiv,  513. 


102  BREAST  FEEDING 

diseases  should  not  nurse  their  babies,  partly  because  their  milk  is 
usually  of  poor  quality,  and  partly  because  the  strain  of  nursing 
is  certain  to  do  them  serious  harm.  It  is  usually  inadvisable  for 
women  that  have  had  severe  hemorrhages,  who  are  septic  or  who 
have  nephritis  to  nurse  their  babies.  Women  suffering  from  puer- 
peral eclampsia  should  not  nurse  their  babies,  because  of  the  danger 
of  the  production  of  serious  or  even  fatal  syraptoms  in  the  babies, 
which  are  probably  manifestations  of  anaphylaxis.  Women  who 
have  been  unable  to  nurse  previous  children  satisfactorily  can 
hardly  be  expected  to  nurse.  It  is  wiser,  however,  for  them  to 
make  the  attempt  because  they  are  sometimes  able  to  do  it,  al- 
though unsuccessful  in  the  past. 

A  certain  number  of  infants  are  unable  to  nurse  because  of 
deformities  of  the  lips  and  mouth.  Premature  infants  are  often  too 
weak  to  nurse,  as  are  some  congenitally  feeble  babies.  Such  babies 
should  not,  however,  be  deprived  of  the  advantages  of  human  milk. 
The  milk  should  be  pressed  from  the  breast,  or  drawn  with  a 
breast  pump  and  fed  to  the  baby  with  a  dropper,  spoon  or  Breck 
feeder,  or  through  a  tube. 


CHAPTER  X 
HUMAN  MILK.    CHEMISTRY  AND  BIOLOGY 

The  Breast  Glands. — Glands  which  secrete  milk  are  present,  as 
a  rule,  in  the  female  mammal  only  during  and  after  pregnancy. 
A  few  drops  of  milk  may  be  squeezed  from  the  breasts  before 
parturition,  but,  generally  speaking,  milk  is  present  in  them  only 
after  delivery. 

According  to  Czemy  and  Keller  ^  if  the  infant  does  not  empty 
the  breasts  and  they  fill  up  again  with  secretion,  there  is  a  change 
in  the  composition  of  the  milk  as  the  result  of  the  absorption  of  its 
different  components.  It  is,  therefore,  necessary  to  differentiate 
between  the  milk  of  women  whose  breasts  are  regulated  and 
sufficiently  emptied  during  nursing  and  those  of  women  whose 
breasts  are  not  sufficiently  emptied.  In  the  first  there  is  no  absorp- 
tion of  the  milk  components  in  the  glands,  while  in  the  latter  the 
chemical  composition  is  more  or  less  changed  by  absorption.  They 
designate  the  latter  as  colostrum.  Under  this  term  they  include 
all  milk  in  which  there  has  been  any  absorption;  not  only  the  milk 
in  the  breasts  during  pregnancy  and  the  first  few  days  postpartum, 
but  also  the  milk  when  the  secretion  is  in  the  process  of  drying  up. 
It  may  also  be  found  in  the  breasts  of  non-pregnant  women,  even 
after  they  have  reached  the  menopause,^ 

Colostrum. — All  authors  agree  that  the  milk  excreted  during  the 
first  few  days  postpartum  differs  essentially  from  that  after  lacta- 
tion is  well  established.  It  is  of  a  deep  lemon-yellow  color.  This 
color  is  present  only  during  the  first  few  days  postpartum  and  is 
never  seen  at  any  later  stage  of  lactation.  Czemy  (p.  408)  be- 
lieves, on  the  basis  of  his  own  work,  that  this  color  is  due  to  a 
coloring  matter  contained  in  the  fat  drops.  The  colostrum  is  not 
as  sweet  as  the  later  milk.  It  is  coagulated  into  soHd  masses  by 
heat.  This  depends,  according  to  Tiemann,^  on  the  presence  of  a 
globulin,  which  coagulates  at  72  C.  (161.6  F.).    The  amoimt  of 

^  Czemy  and  Keller:  Dea  Kindes  Emahrung,  EmahrungsstSrungen,  und 
Emahrungstherapie,  Leipzig  and  Wien,  1906,  i,  407. 

*  Gardlund:  Hygiea,  Stockholm,  1917,  Ixxix,  No.  3,  97;  Abstr.  Joxir.  A.  M.  A., 
1917,  Ixviii,  No.  16. 

"Tiemann:  Ztschr.  f.  Physiol.  Chem.,  1898,  xxv,  363. 

103 


104      HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY 

cholesterin  and  lecithin  is  greater  than  in  milk.^  The  fat  in  colo- 
strum contains  less  of  the  volatile  fatty  acids  than  does  normal 
milk.2 

It  is  obvious  that  only  those  analyses  of  colostrum  which  have 
been  made  during  the  first  days  postpartum  are  of  any  value,  as 
later  it  is  mixed  with  milk.  The  specific  gravity  of  colostrum 
ranges  from  1.028  to  1.072,  the  average  being  about  1.040.^  It  has 
a  strongly  alkaline  reaction. 

J.  Konig  *  gives  the  following  percentages  as  the  average  of  five 
analyses  of  early  human  colostrima;  Water,  86.4;  nitrogenous  sub- 
stances, 3.07;  fat,  3.34;  lactose,  5.27;  salts,  0.40. 


TABLE  18 
Composition  of  Colosteum  as  Determined  by  Various  Investigators 

(CZERNY   AND   KeLLER) 


Author 

Day,  post- 
partum 

Fat 

per  cent. 

Lactose, 
per  cent. 

Protein, 
per  cent. 

Nitrogen, 
per  cent. 

Ash. 
per  cent. 

Solids, 
per  cent. 

Pf eiffer  * 

1 

2 

2 
f  26-51  * 
1  56-61  *  t 

126-48* 
1  48-69  *  t 

2.59 
2.17 
3.77 
4.08 
3.92 
1.67 
2.02 

2.76 
3.50 
5.39 
4.09 
5.48 
5.20 
5.08 

9.75 
7.45 
3.31 

6.928 
0.508 
0.336 
0.226 

0.408 

0.340 

0.27 

0.48 

0.41 

0.36 

0.40 

Pf eiff er 

V.  &  J.  Adriance  '^ 
Camerer  and  Sold- 
ner  ^ 

12.78 
16.04 
14.12 

10.32 
10.12 

*  Hours. 


t     Same  woman. 


Pfeiffer,*  found  that  the  nitrogenous  substances  in  human  milk 
were  as  follows:  First  day,  8.6%;  third  to  seventh  day,  3.4%; 
during  second  week,  2.28%;  in  second  month,  1.84%;  in  seventh 
month,  1.52%.  The  amount  of  sugar  increases  as  the  protein  in 
human  milk  diminishes.  The  mineral  composition  of  colostrum 
and  breast  milk  is  materially  different.  Table  19  shows  the  com- 
position of  one  hundred  grams  of  colostrum  as  compared  with  one 
hundred  grams  of  milk.^ 

The  findings  of  Burr,  Bermerich  and  Berg'^  were  somewhat 

*  Voltz:  Oppenheimer's  Handbuch  der  Biochemie,  Jena,  1910,  iii,  I,  382. 
2  Nilson:  Maly's  Jahresb.,  1891,  xxi,  142. 

'  Burr,  Bermerich  and  Berg:  Chem.  Ztg.,  xxxvii,  69-71,  97-101. 

*  Konig,  J. :  Die  Menschl.  Nahrungs  u.  Genussmittel,  Berlin,  1904,  ii,  698. 
6  Pfeiffer:  Jahrb.  f.  Kinderh.,  1883,  xx,  365. 

'  Adriance,  V.  and  J. :  Archives  of  Pediatrics,  1897,  xiv,  22. 
''  Camerer  and  Soldner:  Ztschr.  f.  Biol.,  1898,  xxxvi,  277. 
«Birk:  Monatschr.  f.  Kinderh.,  1910-1911,  ix,  595. 

*  Berg:  Chem.   Ztg.,   xxxvii,   146. 


HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY      105 

different.  They  found  that  colostrum  contained  twice  the  amount 
of  phosphorus,  magnesium  and  calcium  normally  present  in  milk 
after  lacation  is  well  estabUshed. 

Colostrum  Corpuscles. — Microscopically  the  fat   droplets  in 
colostrum  are  more  unequal  in  size  than  in  ordinary  milk.    The 

TABLE  19 
Composition  op  100  Gm.  Colostrum  as  Compared  with  Mas  (Birk)  * 


Colostrum  (Birk) 


Human  milk 


Ash 0.2814 

Calcium 0.0360 

Magnesium 0.0093 

Potassium 0.077 

Sodium 0.0544 

Phosphorus 0.1137 


0.0198 Langstein  and  Meyer 

0.2      -0.25     Abu-Neuberg 

0.0328-0.0343 Bunge 

0.0378 Camerer  and  Soldner 

0.0064-0.0065 Bunge 

0.0053 Camerer  and  Soldner 

0.078  -0.0703 Camerer  and  Soldner 

0.088 Camerer  and  Soldner 

0 .  0357 Camerer  and  Soldner 

0.0473-0.0469 Bunge 

0 .  0591 Camerer  and  Soldner 


colostrum  also  contains  large  numbers  of  granular  bodies,  known  as 
"  colostrum  corpuscles."  They  are  four  or  five  times  as  large  as  the 
leukocytes,  are  nucleated  and  are  full  of  fat  droplets.  They  are 
characteristic  components  of  milk  at  the  beginning  of  lactation, 
and  are  not  found  in  later  lactation.  They  have  ameboid  motion.^ 
Czemy  identified  them  as  large  leukocytes,  whose  cell  membranes 
are  completely  filled  with  fat  drops.  These  fat  drops  are  smaller 
than  those  in  the  milk.  He  was  able  to  demonstrate  that  the  leu- 
kocytes of  frogs  possess  the  power  of  emulsifying  fat  drops  and 
explains  their  small  size  in  this  way.  He  further  emphasized  the 
fact  that  it  had  previously  been  thought  that  these  bodies  were 
only  present  in  the  milk  during  the  first  days  of  lactation.  Buch- 
holz  ^  noticed  in  1877,  however,  that  the  colostrum  bodies  reap- 
peared in  the  milk  when  nursing  was  stopped  and  the  milk  was 
drying  up.  Czemy  repeated  his  work  and  found  that  the  colostrum 
bodies  always  reappeared  in  the  milk  when  lactation  was  inter- 
rupted for  a  few  days,  and  that  their  numbers  increased  in  direct 
proportion  to  the  length  of  time  which  had  clasped  since  the  breasts 
were  emptied.  He  concluded  that  colostrum  corpuscles  were  al- 
ways present  when  milk  was  formed  in  the  breasts  but  was  not 
withdrawn  and  that  they  disappeared  when  the  breasts  were  suffi- 


*  Czemy  and  Keller,  page  409. 


*  Czemy  and  Keller,  page  410. 


106      HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY 

ciently  emptied  of  milk.  Animal  experiments  show  that  the  colo- 
stnmi  bodies  pass  from  the  breasts  into  the  Ijonphatics.  These 
colostrum  corpuscles  contain  neutrophilic  granules.  ^  According  to 
Deville,^  they  disappear  from  the  milk  between  the  eighth  and 
tenth  day  in  51%  of  the  cases.  They  may,  however,  in  rare  in- 
stances persist  for  many  weeks.' 

They  are  also  phagocytic,  in  that  they  will  consume  bacteria. 
They  have  been  shown  to  consume  staphylococci,  the  colon  bacil- 
lus, and  the  tubercle  bacillus.^ 

When  the  breasts  are  not  completely  emptied,  the  protein  and 
sugar  are  reabsorbed  into  the  body  earher  than  the  fat,  which  is 
taken  up  by  the  colostrum  corpuscles  only  after  five  or  six  days. 
The  sugar  may  appear  early  in  the  urine.  The  albumins  in  milk 
have  a  different  hemolytic  action  from  those  in  the  blood  of  the 
same  species,  while  those  in  colostrum  react  the  same.  On  the 
basis  of  these  facts,  Bauer  ^  argues  that  the  proteins  in  colostrum 
are  a  direct  transudate  from  the  blood,  while  those  in  milk  are 
manufactured  by  the  mammary  gland. 

The  protein  of  colostrum  is  characteristic  since  the  greatest  part 
of  it  will  coagulate.  Acid  coagulation  occurs  very  easily  and  the 
curd  is  tough. 

The  colostral  fat  is  richer  in  oleic  acid  than  is  milk  fat  and  as  a 
result  the  iodin  index  is  considerably  higher.* 

HUMAN   MILK 

Bacteriology. — Since  the  infant  takes  the  milk  directly  into 
the  mouth  from  the  breasts,  only  such  organisms  as  are  in  the 
breast  gland  itself  can  get  into  the  milk.^ 

1  Cohn:  Virchow's  Arch.  f.  path.  Anat.,  1900,  clxii,  187. 

*  Deville:  Arch,  internat.  de  mdd.  leg.,  1913,  iv,  60. 
3  Steele:  Arch.  Pediat.,  1910,  xxvii,  32. 

*  Thomas:  Vortr.  geh.  a.  d.  Vereinig,  Sachs-Thuring;  Kinderarzte  in  Dres- 
den, 1913,  Ref.;  Ztschr.  f.  Kinderh.  (Ref.),  1913,  vi,  28. 

^  Bauer:  Deutsch,  med.  Wochenschr.,  1909,  xxxv,  1657. 

« Engel:  In  Sommerf eld's  Handbuch  der  Milchkunde,  Wiesbaden,  1909, 
p.  810. 

^Escherich:  Fortschr.  d.  Med.,  1885,  iii,  231;  Cohn  and  Newmann:  Vir- 
chow's Arch.  f.  path.  Anat.,  1891,  cxxvi,  391;  Palleske:  Virchow's  Arch.,  1892, 
cxxx,  185;  Honigmann:  Ztschr.  f.  Hyg.  u.  Infectionskr.,  1893,  xiv,  207;  Ringel: 
Miinchen.  med.  Wochenschr.,  1893,  xl,  513;  Genoud:  Sur  la  presence  du  staphy- 
locoque  dans  la  lait  des  accouch6es  bien  portantes,  Thfese  de  Lyon,  1894; 
Knochenstiem:  Hyg.  Rundschau,  1894,  iv,  231;  Halleur:  Inaug.  Diss.  Leipzig, 
1893;  Brumm:  Arch.  f.  Gynaecol.,  1886,  xxvii,  461;  Merit:  Thtee  de  Paris, 
1887;  Johanessen:  Jahrb.  f.  Kinderh.,  1895,  xxxix,  398;  Roep)er:  Inaug.  Diss., 
Marburg,  1896;  Koestlin:  Arch.  f.  Gynaecol.,  1897,  liii,  201. 


HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY      107 

These  investigations  show  that  the  milk  of  healthy  women, 
whose  breasts  are  free  from  pathologic  conditions,  contains  micro- 
organisms in  the  majority  of  instances.  In  the  majority  of  cases 
the  organism  is  staphylococcus  aureus.  Most  investigators  be- 
Ueve  that  the  bacteria  get  in  from  the  outside.  Evidence  in  favor 
of  this  view  is  the  fact  that  it  is  easier  to  demonstrate  these  or- 
ganisms in  the  first  part  of  the  milk  drawn  than  in  the  last  part. 
Finally  when  the  milk  is  withdrawn  gently  drop  by  drop,  rather 
than  strongly  and  rapidly,  many  tests  are  sterile.  This  fact  makes 
it  seem  probable  that  the  rough  handling  of  the  breast  gland  during 
nursing  or  by  massage  dislodges  the  bacteria  and  forces  them  into 
the  milk. 

S3rphihtic  lesions  have  been  induced  in  rabbits  by  inoculating 
them  with  milk  from  syphiUtic  women,  although  the  milk  was 
sterile  and  no  spirochaeta  pallida  were 'found  in  the  milk.* 

Typhoid  bacilli  have  been  found  by  Lawrence  ^  in  the  milk  of 
a  woman  suffering  with  typhoid  fever. 

Under  normal  conditions  no  ill  effects  are  caused  by  the  bac- 
teria in  human  milk.  The  children  who  take  this  milk  thrive  in 
spite  of  the  presence  of  bacteria  in  the  first  portion  of  the  milk. 
The  bacteria  in  human  milk  have  no  pathologic  significance  for 
the  healthy  infant.  It  has  been  shown  that  this  is  not  the  fact  in 
babies  with  disturbances  of  digestion.  Moro  *  has  recently  as- 
cribed to  the  staphylococci  in  human  milk  an  etiologic  r61e  in  the 
dyspeptic  conditions  of  breast-fed  infants. 

Appearance,  Smell  and  Taste. — Human  milk  has  the  same 
appearance  as  cow's  milk,  except  that,  when  it  is  cooled,  small 
white  flakes  are  apt  to  stick  to  the  side  of  the  bottle.  These  flakes 
disappear  when  the  milk  is  warmed.  It  has  no  odor  and  its  taste 
is  sweet.  The  color,  however,  varies  in  different  milks  from  a 
rich  yellow,  creamy  appearance  to  a  bluish  white.  The  former  is 
supposed  to  contain  more  fat  than  the  latter;  this,  however,  is 
not  always  the  case  as  is  shown  by  two  milks  examined  by  Dr. 
Dennis  at  the  Mass.  Gen.  Hospital  (not  yet  reported),  whose 
color  was  a  rich  yellow  and  contained  less  than  1%  of  fat.  If  the 
nursing  mother  eats  fiver,  a  green  coloration  often  appears  in  the 
milk  about  sixteen  hours  after  the  meal.  This  color  is  probably 
due  to  bile  salts.^ 

Microscopic  Appearance. — It  contains  many  minute  fat  drop- 

*  Uhlenhuth  and  Mulzer:  Deutsch.  med.  Wochenschr.,  1913,  xxziz,  No.  19. 

*  Lawrence:  Boston  Med.  and  Surg.  Jour.,  1909,  cbd,  152. 
»  Moro:  Jahrb.  f.  Kinderh.,  lii,  542. 

*  Feer:  Zurich  Biochem.  Zeitschr.,  1916,  Ixxii,  378. 


108      HUMAN  MILK,  CHEMISTRY  ANN  BIOLOGY 

lets  which  are  held  in  a  state  of  permanent  emulsion  by  the  solu- 
tion in  which  they  are  suspended.  It  may  contain  a  few  leuko- 
cytes and  epithelial  cells.  The  ultramicroscope  shows  numerous 
fine  particles  in  Kvely  molecular  motion  between  the  fat  droplets. 
These  particles  are  less  mmierous  than  in  cow's  milk.  They  are 
composed  of  casein.* 

Specific  Gravity. — The  specific  gravity  averages  between  1.030 
and  1.032.    It  may  fall  as  low  as  1.020  and  rise  as  high  as  1.036.^ 

Reaction. — The  reaction  of  human  milk  is  amphoteric.  It  is 
acid  to  phenolphthalein  and  alkaline  to  litmus.  The  reason  for 
the  double  reaction  is  the  fact  that  the  milk  contains  both  mono- 
and  diphosphates.  The  former  are  weakly  acid,  while  the  latter 
react  as  a  base.  If  10  c.  c.  of  human  milk  are  titrated  with  deci- 
normal  acid  and  litmus,  it  will  require  about  0.9  to  1.25  N/10  acid 
to  neutralize  them;  it  requires  0.12  to  0.55  N/10  NaOH  with 
phenolphthalein.  One  hundred  cubic  centimeters  of  milk  require 
60  to  80  c.  c.  N/10  HCl  to  show  the  Gunzburg  reaction.^  The 
alkahne  reaction  of  human  milk  is  relatively  stronger  than  the  acid 
reaction,  but  the  absolute  amount  of  acidity  and  alkalinity  are  less 
than  in  cow's  milk.  The  electrical  measurement  of  human  milk  as 
well  as  of  all  other  milks  is  neutral.^  The  average  hydrogen  ion 
concentration  is,  according  to  Clark,^  between  1.07  and  .60  X  10"''. 

Quantity. — The  amount  of  human  milk  secreted  by  healthy 
mothers  depends  on  the  demands  of  the  infant.  The  twenty-four- 
hour  amount  of  milk,  therefore,  depends  in  large  part  on  the 
weight  and  strength  of  the  infant.  It  is  obvious  that  what  might 
be  a  normal  amount  for  one  infant  would  be  abnormal  for  another, 
and  for  this  reason  averages  are  of  no  greater  value  than  the  aver- 
age weight  of  the  infant.  The  figures  representing  the  amount  of 
milk  taken  by  the  infant  are  obtained  by  weighing  either  the 
mother  or  the  baby  before  and  after  each  nursing.  The  table  of 
Cramer's  ^  figures  shows  the  difference  between  the  secretion  of 
milk  in  primiparse  and  multiparse: 

^  Alexander  and  Bullowa:  Jour.  Am.  Med.  Assn.,  1910,  Iv,  1196;  Mauntner: 
Arch.  f.  Kinderh.,  1908-9,  xlix,  29;  Kreidl  and  Neumann:  Pfliiger's  Arch., 
1908,  cxxiu,  523. 

^Engel:  In  Sommerfeld's  Handbuch  der  MUchkunde,  Wiesbaden,  1909, 
p.  774;  Konig:  Note  9. 

^  Courant:  Pfliiger's  Arch.,  1891,  i,  109;  Escherich:  Verhandl.  d.  Versamml. 
d.  Ges.  f.  Kinderh.,  Heidelberg,  1889,  109. 

2Foa:  Soc.  Biol.,  1905,  Iviii,  863;  1905,  lix,  51. 

'  Clark:  Jour.  Med.  Research,  N.  S.,  1915,  xxvi,  431. 

*  Cramer:  Klin.  Beitr.  z.  Frage  der  kunstlichen  Emahrung  des  Neuge- 
borenen.  Inaug.  Diss.,  Breslau,  1896.  Taken  from  Czemy  and  Keller,  Des 
Kindes,  etc.,  Vol.  1,  p.  356. 


HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY      109 

TABLE  20 
Twenty-Four  Hour  Amount  of  Milk  in  Grams 


Day  -postpartum 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

Nine  babies  of  primiparae; 
average    birth    weight, 
3,290  gm 

4 
6 

78 
129 

183 
238 

199 
324 

236 
344 

299 
324 

303 
361 

274 
365 

362 
384 

384 

Seven    babies    of    mnlti- 
parae;      average      birth 
weight,  3,348  gm 

415 

Table  21  from  Czerny  and  Keller  ^  gives  the  figures  that  Feer 
calculated  as  the  amount  of  milk  babies  of  the  average  weight 
(Camerer's  figures)  would  take  in  a  day.  They  do  not  dijEfer 
much  from  those  given  by  Camerer. 

Czerny  and  Keller  ^  (Vol.  I,  Chapter  18)  should  be  consulted 
for  a  more  detailed  discussion  of  the  amounts  of  breast  milk  se- 
creted by  the  average  woman.  These  amounts  may  be  increased 
when  a  woman  nurses  two  or  more  babies  as  does  the  wet-nurse. 
A  wet-nurse^  increased  the  amount  of  milk  secreted  in  ten  days 
from  720  grams  when  she  nursed  two  infants  to  1,750  grams  when 
she  nursed  five  infants. 

TABLE  21 
Average  Daily  Amount  of  Milk  Drawn  by  a  Baby  (From  Czerny  and 

Keller) 


Average 

Average 

weight  of 

weight  of 

breast-fed 

The  calcu- 

breast-fed 

The  calcu- 

Age in 

babies  ac- 

lated day's 

Age  in 

babies  ac- 

lated day's 

weeks 

cording  to 

amount  of 

weeks 

cording  to 

amount  of 

Camerer, 

milk,  gm. 

Camsrer, 

milk,  gm. 

gm. 

gm. 

1 

3,410 

291 

14 

5,745 

870 

2 

3,550 

549 

15 

5,950 

878 

3 

3,690 

590 

16 

6,150 

893 

4 

3,980 

652 

17 

6,350 

902 

5 

4,115 

687 

18 

6,405 

911 

6 

4,260 

736 

19 

6,570 

928 

7 

4,495 

785 

20 

6,740 

947 

8 

4,685 

804 

21 

6,885 

956 

9 

4,915 

815 

22 

7,000 

958 

10 

5,055 

800 

23 

7,150 

970 

11 

5,285 

808 

24 

7,285 

980 

12 

5,455 

828 

25 

7,405 

990 

13 

5,615 

852 

26 

7,500 

1,000 

»  Czerny  and  Keller:  i.  353. 


Czerny  and  Keller:  358. 


110      HUMAN  MILK   CHEMISTRY  AND  BIOLOGY 

Coagulatioii. — The  recent  observations  with  the  ultramicro- 
scope  ^  have  helped  to  explain  the  coagulation  of  milk.  The  essen- 
tial differences  in  the  coagulation  of  human  and  cow's  milk  are 
as  follows:  The  casein  of  human  milk  is  precipitated  with  greater 
difficulty  with  acids  or  salts  and  it  does  not  coagulate  uniformly- 
after  the  addition  of  rennet;  and,  lastly,  the  clot  that  forms  does 
not  appear  in  such  large  coarse  masses  as  the  casein  from  cow's 
milk,  but  is  more  loose  and  flocculent. 

(a)  Precipitation  with  Adds. — Bienenfeld  ^  showed  that  there 
is  a  certain  acidity  at  which  the  casein  is  precipitated  most  easily. 
When  lactic  acid  is  used,  this  point  is  between  22  and  24  c.  c.  N/10 
acid  to  100  c.  c.  of  milk.  If  the  milk  is  made  acid  up  to  this  point 
and  warmed  to  40  C.  (104  F.)  the  casein  precipitates  out  of  the 
solution.  If  the  milk  is  diluted  five  times,  the  precipitation  is 
accelerated.  A  watery,  clear  whey  is  left  behind.  Engel  ^  showed 
that  this  was  also  true  of  strong  acids  (20  to  30  c.  c.  N/10  acid  to 
100  c.  c.  milk),  but  the  best  results  were  only  seen  at  a  certain  de- 
gree of  acidity.  Shght  variations  above  or  below  this  point  did 
not  give  good  results.  When  acetic  acid  is  used,  more  is  neces- 
sary, i.  e.,  60  to  160  c.  c.  N/10  of  the  acid  to  100  c.  c.  milk. 

(b)  Rennin  Coagulation. — If  a  neutral  solution  of  rennet  is 
added  to  milk  there  is  no  macroscopic  or  microscopic  change  un- 
til the  milk  is  acidified,  but  the  ultramicroscope  shows  that  the 
rennin  ferment  acts  also  in  neutral  solutions.^  Although  human 
milk  does  not  coagulate  uniformly  with  rennin,  it  has  been  shown 
that  it  is  capable  of  coagulation.^  After  human  milk  has  been 
frozen  several  days  and  then  rennin  plus  acid  are  added,  there  is  a 
definite  coagulation.  Human  milk  does  not  coagulate  with  rennin 
alone.  Two  factors  may  explain  the  diminished  coagulability  of 
human  milk,  viz.,  the  relative  alkalinity  of  the  milk  and  its  low 
calcium  content.^  Engel  ^  saw  a  better  precipitation  when  he 
diluted  the  milk  with  water  that  contained  calcium,  than  when  he 
used  distilled  water.  The  coagulation  is  also  faciUtated,  if  the 
milk  is  kept  cold  for  several  hours.* 

The  precipitate  is  characteristic  and  is  always  in  more  or  less 
fine  curds,  which  are  never  as  large  as  the  curd  from  acidified  cow's 

^  Czerny  and  Keller:  i,  458. 

"Bienenfeld:  Biochem.  Ztschr.,  1907,  vii,  262. 

» Engel:  loc.  cil.,  Note  19,  p.  775. 

*  Kreidl  and  Neumann:  (See  note  4,  97). 

'Schlossmann  and  St.  Engel:  Oppenheimer's  Handbuch,  etc.,  iii,  430. 

«  Fuld  and  Wohlgemuth:  Biochem.  Ztschr.,  1907,  v.  119. 

"Engel:  Biochem.  Ztschr.,  1908,  xiii,  89. 

» L.  F.  Meyers:  Verhandl.  d.  ges.  f.  Kinderh.,  Stuttgart,  1906,  p.  122. 


HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY      111 

milk.  The  curds  in  undiluted  milk  are  especially  fine  and  can  be 
seen  only  with  the  microscope.  It  is  interesting  that  they  do  not 
sink  to  the  bottom  in  milk  from  which  the  cream  has  not  been 
removed,  but  rise  to  the  top.  In  skimmed  milk  they  may  fall  to 
the  bottom. 

(c)  The  Difference  between  Acid  and  Rennin  Coagulation. — 
There  is  no  macroscopic  difference.  The  ultramicroscope  shows 
that  neutral  solutions  of  rennin  cause  the  casein,  which  was  pre- 
viously invisible,  to  become  visible,'  Acid  must  subsequently 
be  added  to  cause  a  definite  precipitation.  The  curds  from  acid 
plus  rennin  coagulation  are  not  so  easily  dissolved  as  those  from 
acid  coagulation  alone.  Chemically  there  results  from  rennin 
coagulation  a  casein  body,  which  is  rich  in  calcium — paracasein. 
The  whey  which  results  from  rennin  and  acid  coagulation,  con- 
tains less  nitrogen  than  that  from  acid  precipitation.^ 

Chemical  Composition. — ^The  principal  components  of  milk  are 
fat,  lactose,  proteins,  salts  and  water.  It  also  contains  small 
amounts  of  extractives  and  citric  acid  as  well  as  certain  unknown 
substances. 

Nitrogenous  Bodies. — 1.  Total  Nitrogen.  The  total  nitrogen 
in  milk  is  usually  determined  by  the  Kjeldahl  method  and  this 
figure  is  multiplied  by  the  factor  6.25,  or  6.37,  to  give  the  protein 
content.  This  method  is,  however,  not  free  from  error,  because 
there  are  other  bodies  that  contain  nitrogen  and  yet  are  not  classed 
among  the  proteins.  These,  according  to  various  authors,^  may 
make  up  between  17  and  20%  of  the  total  nitrogen.  Taking  this 
fact  into  consideration  and  deducting  the  non-protein  nitrogen 
from  the  total  nitrogen,  there  is,  according  to  Camerer  and  Soldner, 
1.04%  of  protein  in  human  milk.  The  average  figures  as  to  the 
total  amount  of  nitrogen  in  100  c.  c.  of  milk  at  different  stages  of 
lactation  are '  as  shown  in  the  following  table: 

^Engel:  In  Sommerfeld's  Handbuch  der  MUchkunde,  Wiesbaden,  1909, 
p.  810. 

« Camerer  and  Soldner:  Ztschr.  f.  Biol.,  N.  F.,  1898,  xviii,  277;  Rietschl: 
Jahrb.  f.  Kinderh.,  Ixiv,  125. 

» Schlossmann:  Arch.  f.  Kinderh.,  1900,  xxx,  324;  1902,  xxjoii,  187. 


112      HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY 


TABLE  22 

Total  Nitrogen  in  100  C.  C.  Milk  at  Dippekent  Stages  in  Lactation 

(Schlossmann) 


Days  postpartum 

Total  nitrogen 

Nitrogen  factor  X6 .25 

9  to    10 

0.29 

1.81 

11  to    20 

0.29 

1.81 

21  to    30 

0.31 

1.94 

31  to    40 

0.24 

1.60 

41  to    50 

0.28 

1.75 

51  to    60 

0.25 

1.56 

61  to    70 

0.23 

1.44 

71  to  100 

0.20 

1.25 

101  to  140 

0.20 

1.25 

141  to  200 

0.207 

1.29 

over  200 

0.21 

1.31 

The  amount  of  protein  varies  in  the  milk  of  different  women. 
Hammett/  found  that  on  the  third  day  it  was  3.52%,  and  dropped 
rapidly  so  that  on  the  eleventh  day  it  was  1.46%.  This  latter 
figure  is  considerably  lower  than  that  given  by  Schlossmann  for  the 
same  period. 

The  amount  of  protein  in  the  milk  varies  during  the  same  day 
and  even  during  a  single  nursing.  These  variations  are,  however, 
not  of  any  great  significance.  The  next  table  shows  the  variations 
in  the  milk  of  eight  wet-nurses  during  a  single  day,  samples  having 
been  taken  from  each  of  the  nursings.  The  individual  variations 
are  so  slight,  however,  that  if  the  average  for  the  day  is  taken 
and  compared  with  the  average  for  the  stage  of  lactation,  the  same 
diminution  in  the  amount  of  protein  during  the  progress  of  lacta- 
tion is  seen  as  in  the  table.^  (The  factor  of  nitrogen  times  6.25 
was  used.) 

^  Hammett:  Jour.  Biol.  Chem.,  1917,  xxix,  381. 

^  Engel :  In  Sommerfeld's  Handbuch  der  Milchkunde,  Wiesbaden,  1909, 
p.  810. 


HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY      113 


TABLE  23 

Variation  op  the  Per  Cent,  op  Protein  in  the  Milk  op  Eight  Wetv 
Nurses  During  a  Single  Day  (Engel) 


Age 

Day 

of 

of 

Morn- 

After- 

nurse, 

lactam 

Am't, 

ing 

noon 

Avg. 

years 

tion 

c.  c. 

5 

9 

12 

3 

6 

10 

16 

45 

2,000 

1.386 

1.458 

1.305 

1.324 

1.306 

1.279 

1.344 

19 

58 

1,500 

1.163 

1.118 

0.956 

1.073 

1.163 

1.127 

1.100 

29 

60 

2,200 

1.149 

1.154 

1.395 

1.261 

1.136 

1.161 

1.208 

25 

70 

2,700 

1.314 

1.243 

1.127 

1.216 

1.046 

1.064 

1.170 

23 

72 

3,000 

1.207 

1.234 

1.154 

1.315 

1.154 

1.163 

1.204 

21 

100 

3,300 

1.135 

1.117 

1.127 

1.154 

1.243 

1.028 

1.119 

19 

130 

1,800 

0.492 

1.019 

1.127 

1.064 

0.903 

1.082 

0.948 

25 

140 

2,200 

1.082 

1.064 

1.100 

0.939 

1.082 

1.064    1.036 
Avg.  1.141 

2.  Residual  Nitrogen. — The  residual  nitrogen  is  that  fraction 
of  the  nitrogen  which  is  found  in  the  filtrate  after  the  precipita- 
tion of  the  albumins  and  which  does  not  give  the  reactions  for 
protein.^  Part  of  this  residual  nitrogen  is  supposed  to  be  in  the 
form  of  urea  (50%  or  more)  and  another  part  in  an  amino-acid  or 
a  peptid-like  body.^  There  is  less  of  it  in  cow's  milk  than  in  hu- 
man milk.    The  significance  of  these  bodies  is  unknown. 

The  milk  and  blood  serum  of  a  21-year-old  primipara  with 
chronic  nephritis  (urinary  albumin  =  0.3%)  were  simultaneously 
examined  on  two  occasions.  The  residual  nitrogen  of  the  serum 
was  5.33%  and  7.43%  of  the  total  nitrogen;  that  of  the  milk  was 
27.19%  and  32.88%,  both  being  much  above  the  normal.  Urea 
was  considered  to  be  the  probable  cause  of  this  increased  amount.' 

3.  The  Albuminous  Bodies. — Human  milk  contains  two  groups 
of  albuminous  bodies:  (1)  casein,  which  is  insoluble  in  water,  and 
(2)  ladalbumin  and  globulin,  which  are  soluble  in  water.  The 
separation  of  these  bodies  in  human  milk  is  more  difficult  than  in 
cow's  milk,  because  of  the  difficulty  in  precipitating  the  casein. 
There  is,  on  this  account,  much  opportunity  for  future  investiga- 
tions to  add  to  our  knowledge  of  the  proteins  of  human  milk.  The 
figures  which  are  most  generally  adopted  are  those  of  Schloss- 


»Munk:  Virchow's  Arch.  f.  path,  Anat.,  1893,  134,  501,     (First  studied 
this  body.) 

*  Rietschel:  Jahrb.  f.  Kinderh.,  Ixiv,  125. 

*  St.  Engel  and  Murschauser:  Ztschr.  f.  physiol.  Chem.,  1911,  Ixxiii,  101. 


114      HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY 

maiin/  who  found  that  about  41%  of  the  total  nitrogen  is  in  the 
form  of  casein.  From  15  to  20%  of  the  total  nitrogen  may,  how- 
ever, be  residual  nitrogen  (see  above).  If  this  amount  is  deducted 
only  44  to  39%  are  left  to  be  divided  between  the  lactalbumin  and 
globuhn.  Ciccarelli  ^  found  that  the  relation  of  casein  to  lactal- 
bumin in  human  milk  was  26.9-37.9  to  62.1-73.1.  These  figures 
show  that  there  is  considerable  variation  in  the  quantities  of  these 
bodies  even  in  human  milk.  The  following  figures  represent  what 
may  be  considered  averages.  The  total  protein  is  divided  as  fol- 
lows: 

Casein,  41%;  lactalbumin  and  globulin,  44  to  39%;  residual 
nitrogen,  15  to  20%. 

Opalisin  was  described  in  1888  by  Wroblewski  ^  as  a  new  al- 
bumin which  is  present  in  very  small  amounts  in  cow's  milk  and 
in  large  amount  in  mare's  milk.  It  is  also  present  in  human  milk. 
Very  little  is  known  about  this  body. 

COMPARISON  OF  PROTEINS  OF  HUMAN  AND   COW's  MILK 

Casein. — ^The  facts  that  it  is  difficult  to  precipitate  casein  from 
human  milk  and  that  it  takes  large  amounts  of  milk  to  obtain  a 
sufficient  quantity  of  casein  for  analysis  have  retarded  our  knowl- 
edge of  the  subject.  For  this  reason  more  is  known  about  cow 
casein  than  human  casein. 

Casein  is  insoluble  in  water,  but  is  soluble  in  water  to  which 
alkahes  have  been  added.  If  acid  is  added  to  this  alkaUne  solu- 
tion, the  casein  will  again  be  precipitated.  If  enough  alkali  is 
subsequently  added  it  will  again  go  into  solution.  The  analysis 
of  casein  is  shown  in  Table  24. 


TABLE  24 
Analysis  op  Casein  (From  Engbl) 


AiUhor 

C 

H 

S 

P 

N 

Wroblewski  * 

52.24 
53.01 
52.63 

7.32 
7.14 
6.94 

1.12 
0.71 
0.85 

0.68 
0.25 
0.27 

14  97 

Bergell  and  Langstein  ' .  . . 

14.60 
14.34 

^  Rietschel:  Jahrb.  f.  Kinderh.,  Ixiv,  125. 

*  Ciccarelli:  La  Pediatria,  1908,  vi,  12. 

»  Wroblewski:  Ztschr.  f.  Physiol,  Chem.,  1898-99,  xxvi,  308. 

*  Wroblewski:  Ztschr.  f.  Physiol.  Chem.  1898-99,  xxvi,  308. 

*  Bergell  and  Langstein:  Jahrb.  f.  Kinderh.,  1908,  Ixviii,  568. 


HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY      115 
The  sulphur  content  of  cow  and  human  casein  is  as  follows: 

Cow  Casein  Human  Casein 

liebig  ^  Hempel  ^  Liebig  Hempel 

0.723  0.723  0.094r-1.079  1.072 

According  to  these  figures  there  is  more  sulphur  in  human  than 
in  cow's  milk.  They  correspond  closer  to  Wroblewski's  figures 
than  to  those  of  Bergell  and  Langstein.  It  is  still  a  disputed  ques- 
tion whether  the  casein  from  different  kinds  of  milk  is  identical 
or  whether  there  are  several  different  caseins.  Recently  Lang- 
stein and  Edelstein  found  that  the  phosphorus  content  of  human 
milk  was  0.22  to  0.28%  and  that  of  cow's  milk  0.85  to  0.87%  and 
concluded  that  this  was  evidence  that  the  two  caseins  were  dif- 
ferent compounds. 

Bordet  ^  showed  that  repeated  injections  of  cow's  milk  into 
other  animals  caused  a  body  to  appear  in  the  blood  which  precipi- 
tated the  albuminous  bodies  of  cow's  milk  and  made  them  co- 
agulate. Wasserman  ^  and  others  went  a  step  further  and  showed 
that  the  blood  serum  of  animals  sensitized  to  cow's  milk  would 
precipitate  the  albuminous  bodies  in  cow's  milk,  but  would  not 
precipitate  those  in  human  milk  or  the  milk  of  other  animals, 
and  that  the  blood  serum  of  animals  sensitized  to  hmnan  milk 
precipitates  the  albuminous  bodies  in  human  milk  and  does  not 
precipitate  them  in  the  milk  of  other  animals.  In  other  words, 
the  blood  serum  of  an  animal  may  be  sensitized  to  the  albumins 
of  a  certain  species  of  animal  and  react  specifically  to  that  species. 
These  experiments  can  leave  no  doubt  that  the  proteins  of  dif- 
ferent animals  are  different. 

Further  investigations  showed  that  casein,  lactalbiunin  and 
globulin  could  be  differentiated  from  one  another  by  complement 
fixation  and  anaphylaxis  experiments.*  Milks  of  animals  of  one 
species  can,  therefore,  be  differentiated  from  the  milk  of  animals 
of  another  species  and  the  casein,  globulin  and  lactalbumin  of  the 
same  milk  can  be  differentiated  one  from  the  other. 

Fat. — ^The  fat  in  human  milk  is  in  a  very  fine  emulsion.  When 
the  number  of  drops  are  counted  in  a  counting  chamber  there  are 

>  Engel:  In  Sommerfeld's  Handbuch  der  Milchkimde,  Wiesbaden,  1909, 
p.  810. 

*  Bordet:  Ann.  de  I'lnst.  Pasteur,  1899,  xiii,  240. 

»  Wasserman:  Verhandl.  des  18  Congr.  f.  inn.  Med.,  1900,  p.  601. 

*  Bauer  and  St.  Engel:  Biochem.  Ztschr.,  1911,  xxxi,  46;  Kleinschmidt: 
Monatschr.  f.  Kinderh.,  1911-1912,  x,  402. 


116      HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY 

always  more  in  human  milk  than  in  cow's  milk.^  The  fat  globules 
in  human  milk  measure  between  0.001  and  0.02  mm.,  while  those 
in  cow's  milk  measure  0.0016  to  0.01  mm.^  Since  the  measure- 
ments given  above  show  that  the  fat  drops  in  human  milk  may  be 
of  greater  diameter  than  those  in  cow's  milk,  it  seems  inconsistent 
that  there  should  be  a  larger  number  in  the  former  than  in  the 
latter.  The  explanation  must  be  that  the  majority  of  fat  drops 
in  human  milk  are  small  and  measure  about  0.001  mm.,  while  the 
majority  of  those  in  cow's  milk  must  be  closer  to  the  upper  limit 
and  measure  nearly  0.01  mm. 

The  source  of  milk  fat  is,  of  course,  the  food.  Fat  is  not  ab- 
sorbed unchanged,  though  it  may  be  re-converted  into  its  original 
form  after  its  passage  out  of  the  alimentary  canal.  Recent  evi- 
dence shows  that  if  large  amounts  of  cotton  seed  oil  are  fed  to 
cattle,  some  of  its  elements  pass  into  the  milk.^  Arguing  by 
analogy,  it  is  possible  that  if  given  in  sufficient  quantities,  un- 
changed fat  may  pass  in  a  similar  manner  into  human  milk. 

Percentage  and  Quantity  of  Fat. — The  figures  as  to  the  per- 
centage of  fat  and  the  total  amount  of  fat  in  human  milk  vary 
considerably  according  to  the  various  investigators  and  the  meth- 
ods they  pursue  in  obtaining  their  material.  Engel's*  mono- 
graph on  human  milk  gives  the  most  complete  summary  of  the 
knowledge  of  this  subject  and  is  quoted  freely  in  the  following 
paragraphs.  The  percentage  of  fat  is  smallest  at  the  beginning  of 
nursing  and  largest  at  the  end  of  nursing,  the  steepness  of  the 
curve  depending  on  the  total  amount  of  milk  taken  at  a  nursing. 
When  a  small  amount  is  taken,  there  is  a  sharp  rise  in  the  percent- 
age of  fat,  and  when  there  is  a  large  amount  of  milk  taken,  there 
is  a  more  gradual  rise.  Although  the  percentage  may  increase 
regularly  throughout  the  nursing,  this  is  by  no  means  the  rule. 
The  three  curves  taken  from  Engel  give  examples  of  how  the 
percentages  of  fat  may  increase  (see  Chart). 

The  percentage  of  fat  in  the  first  milk  drawn  varies  between  1 
and  3%  and  that  in  the  last  milk  taken  between  6  and  10% .  These 
figures  may  occasionally  be  even  higher.  There  are  cases  on  rec- 
ord in  which  there  was  more  fat  in  the  first  part  of  the  milk  than 

1  Czemy  and  Keller:  Des  Kindes;  Emahrung,  Ernahrungsstorungen,  und 
Ernahrungstherapie,  Leipzig  and  Wein,  1906,  1,  407. 

*  Leaves:  Ztschr.  f.  physiol.  Chem.,  1894,  xix,  369;  Ruppel:  Ztschr.  f.  Biol., 
1894,  xxi,  1. 

»  Smith,  Wells,  Ewing:  Bull.  122,  Georgia  Expt.  Station,  June,  1916. 

*  Engel:  In  Sommerf eld's  Handbuch  der  Milchkunde,  Wiesbaden,  1909, 
p.  810. 


HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY      117 

in  the  last  part  and  the  curve  is  the  reverse  of  the  one  just  de- 
scribed.^ 

In  pathological  conditions  the  extremes  of  the  percentage  of 
fat  are  0.1%  ^  and  13.7%.' 

The  average  fat  content  of  the  milk  of  ten  wet-nurses  (German) 
examined  by  Engel  was  4.5%,  and  119  women  (Russian)  ex- 
amined by  Skvortzov,^  3%.  The  amount  of  fat  in  the  milk  of 
the  same  women  may  vary  from  25  to  100%  in  the  same  day  at 
different  nursings.  When  the  intervals  of  emptying  the  breasts 
are  long  there  is  more  milk  and  less  fat.  When  all  the  milk  of  a 
woman  is  collected  each  day  the  average  daily  percentage  is  con- 
stant. This  is  true  even  if  the  total  amoimt  of  milk  is  considerably 
increased. 

Quality  of  Fat. — When  fat  is  separated  from  human  milk  by 
dissolving  it  in  ether,  it  forms  a  yellowish-white  mass  similar,  at 
room  temperature,  to  butter.  Human  milk  may  be  tinted  yellow, 
as  is  cow's  milk,  by  carotin  and  xanthophyll.  The  relative  pro- 
portions of  these  two  pigments  is  much  more  nearly  equal  than  in 
the  fat  of  cow's  milk,  according  to  Palmer  and  Eckles.^ 

1  Engel:  Arch.  f.  Kinderh.,  1906,  xliii,  181. 

*  MoU:  Arch.  f.  Kinderh.,  1908,  xlviii,  161. 
•Engel:  Arch.  f.  Kinderh.,  1906,  xUii,  194. 

*Skvortzov:  Russki  Vratch  ii,  p.  1392;  Ref.  Chem.  Abstracts,  1913,  vii. 
No.  18. 

*  Palmer  and  Eckles:  Jour.  Biol.  Chem.,  1914,  xvii,  191. 


118      HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY 

CHART  IV 

Chart  from  Engel. — The  heavy  black  line  indicates  the  increase  in  the  per 
cent  of  fat  when  the  milk  is  examined  at  frequent  intervals  during  a  single 
nursing. 


FAT 
1' 

7 
6 
5 
4 
3 
2 
1 

WET  -  NURSE  6 
29.  VIII.  '05, 6  P.M. 

FAT 
1' 

1 
6 
5 

4 
3 
2 

1 

WET  -  NURSE  K 

22.  VI.  •os.ep.M. 

FAT 
8 

7 

6 

5 

4 

3 

2 
I 

WET  -  NURSE  H 
13.  V.  -05 

^ 

^ 

^ 

^' 

^; 

/ 

J 

^ 

/' 

y 

/ 

/ 

* 

/" 

^ 

V 

/ 

• 
* 

/ 

y 

t' 

/ 

i 

V 

y 

/' 

^ 

r 

y 

r 

&  &  50  100  ISO 


SO  too  ISO  200  SO  100  ISO  200 


The  melting  point  of  human  milk  fat  is  between  30  and  34  C. 

The  solidifying  point  is  between  19  and  22.5  C. 

The  specific  gravity  at  15  C.  is  0.97.^ 

The  fat  of  human  is  relatively  poor  in  volatile  fatty  acids  when 
compared  with  cow's  milk. 

Volatile  fatty  acid,  human  milk,  2.5%  of  total  fat. 

Volatile  fatty  acid  in  cow's  milk,  27.0%  of  total  fat. 

Among  the  volatile  fatty  acids  have  been  demonstrated  butyric,, 
capronic,  caprinic  and  capryUc  acids.  One-half  of  the  non-volatile 
fatty  acids  are  oleic  acid,  while  among  the  solid  fatty  acids  myristic 
and  palmitic  acids  are  found  to  be  more  abundant  than  stearic 
acid.^  The  large  amount  of  oleic  acid  explains  the  relatively  lower 
melting  point  and  higher  iodia  value  of  human  milk  than  of  cow's 
milk. 

The  iodin  value  of  the  fat  in  human  milk  varies  within  fairly  wide 
limits,  but  is  usually  found  at  about  45.    There  are  women  in 

iRuppel:  Ztschr.  f.  Biol.,  1894,  xxxi,  1;  Laves:  Ztschr.  f.  physiol.  chem., 
1894,  xix,  369;  Sauvaitre:  Ref.,  Malys.  Jahresb.  d.  Tierchemie,  1903,  xxxiii, 
324. 

^Hammersten:  English  translation  Text-book  Physiological  Chemistry, 
N.  Y.,  1909,  p.  530. 


HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY      119 

whom  it  sinks  to  32  and  others  in  whom  it  is  as  high  as  50.^  Cer- 
tain observations  go  to  show  that  the  iodin  value  is  in  part  depend- 
ent on  the  food.  Goose  fat,  linseed  oil  ^  and  iodized  fats  ^  have 
been  demonstrated  to  pass  from  the  food  into  the  milk. 

Lactose. — Lactose,  or  milk  sugar,  is  found  only  lq  the  milk 
of  animals.  It  is  essentially  the  same  in  the  milk  of  the  woman,  the 
cow,  ass,  rabbit,  dog  and  horse.^  There  is  evidence  ^  which  sug- 
gests strongly  that  lactose  is  formed  from  the  dextrose  in  the 
blood.  The  quantity  of  lactose  varies  the  least  of  all  the  elements, 
of  human  milk.  The  amount  of  lactose  in  human  milk  is  almost 
twice  that  in  cow's  milk,  being  on  the  average  about  7%.  The 
lowest  percentage  which  has  been  found  is  4.22  ^  and  the  highest 
10.9%.^  A  few  instances  have  been  recorded  in  which  the 
addition  of  sugar  to  the  diet  of  the  mother  has  increased  the 
amount  of  sugar  in  the  milk.  This  is,  however,  by  no  means  the 
rule.* 

Lecithin. — It  has  been  estimated  that  100  c.  c.  of  human  milk 
contains  0.058  gm.  of  lecithin.^  The  question  has  been  raised, 
however,  whether  the  body  that  was  quantitated  as  lecithin  was 
not  a  result  of  the  breaking  down  of  some  of  the  phosphorus- 
containing  bodies  by  the  chemical  manipulations  during  the  in- 
vestigation. 

Nuclein. — There  is  considerable  debate  as  to  whether  human 
milk  contains  nuclein  or  not.  Three  cases  which  were  ^amined  ^° 
showed  an  average  per  cent  during  one  year  as  follows:  0.1302, 
0.1339  and  0.1305.  The  amount  was  inversely  proportional  to  the 
quantity  of  the  milk. 

Salts. — Total  Ash:  The  average  amount  of  ash  in  human  milk 
is  about  0.21%.^^  The  amount  of  ash  diminishes  during  the  course 
of  lactation  just  as  does  that  of  the  protein.  This  is  shown  in 
the  following  from  Camerer  and  Soldner: 

^Engel:  In  Sommerf eld's  Handbuch  der  Milchkunde,  Wiesbaden,  1909. 
-  Thieraich:  Monatschr.  f.  Geburtsh.  u.  Gynak.,  1899,  ix,  515. 

*  Bendix:  Deutsch.  med.  Wochenschr.,  1898,  xxiv,  223. 

*  Deniges:  Contribution  a  I'^tude  des  lactoses,  Paris,  1892;  Bonmartini: 
Rev.  g6n.  du  lait,  1906,  ii,  No.  1. 

^Porcher:  Biochem.  Ztschr.,  1909-10,  xxiii,  370;  Paton  and  Cathcart: 
Jour,  of  Physiol.,  1911,  xlii,  179. 

«  Pfeiffer:  Verb.  II,  Versaml.  d.  Gesselsch.  f.  Kinderh.,  Wien,  1894,  p.  131. 

^Schlossmann:  Arch.  f.  Kinderh.,  1900,  xxx,  324. 

«  Lust:  Monatschr.  f.  Kinderh.,  1913,  xi,  236. 

9  Burow:  Ztschr.  f.  Physiol.  Chem.,  1900,  xxx,  506. 

"Valenti:  Chem.  Zentralbl.,  1909,  i,  93. 

"  Camerer  and  Soldner:  See  Note  6,  p.  94;  Pfdffer:  Verb.  d.  gesellsch.  f. 
Kinderh.,  Wien,   1894,  p.   126. 


120      HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY 


Days  postpartum  Per  cent  of  ash 

»-  11  days 0.28 

29-  40  days 0.22 

60-140  days 0. 19 

170  days  and  later 0. 18 

The  following  table  shows  the  percentage  of  the  various  salts  ia 
human  milk  to  100  parts  of  ash: 

TABLE  25 

Average  Percentage  Composition  op  Ash  for  the  Different  Periods 
(Holt,  Courtney  &  Fales)  ' 

CI 


Colostrum 
Transition 
Mature.  .  . 
Late 


CaO 

MgO 

P2O5 

Na-iO 

K1O 

14.2 

3.5 

12.5 

13.7 

28.1 

17.0 

2.4 

16.9 

10.9 

30.8 

23.3 

3.7 

16.6 

7.2 

28.3 

19.8 

3.6 

15.5 

10.1 

28.8 

20.6 
22.9 
16.5 
22.3 


Distribution 

OP  THE  Ash — Ghams  Per  100  c.  c.  of  Milk 

No.  of 
Analyses 

Total 
Ash 

CaO 

MgO 

P2O6 

NaiO 

KtO 

CI 

Colostrum  (1-12  days) 

Transition  (12-30  days) 

Early  mature  (1-4  months) .... 
Middle  mature  (4-9  months). .  . 
Late  milk  (10-20  months) 

5 
6 
9 
8 
10 

.3077 
.2407 
.2056 
.2069 
.1978 

.0446 
.0409 
.0486 
.0458 
.0390 

0101 
.0057 
.0082 
.0074 
.0070 

.0410 
.0404 
.0342 
.0345 
.0304 

.0453 
.0255 
.0154 
.0132 
.0195 

.0938 
.0709 
.0539 
.0609 
.0575 

.0568 
.0580 
.0351 
.0358 
.0442 

The  composition  of  the  ash  of  human  milk  is,  according  to 
Soldner  ^  as  shown  in  Table  26. 

TABLE  26 
Composition  op  Ash  of  Human  Milk  (From  Engel) 


100  gm.  milk  contains, 
milligrams 

100  gm.  ash  contains, 
milligrams 

First  milk 

End  milk 

Average 

First  milk 

End  milk 

Average 

K20 

100.8 

44.8 

37.6 

5.4 

0.22 

32.10 

9.6 

71.7 

63.4 

17.6 

38.1 

5.2 

0.12 

28.8 

7.2 

34.2 

88.4 

35.7 

37.8 

5.3 

0.2 

31.0 

9.0 

59.1 

32.5 

14.5 

12.1 

1.7 

0.07 

10.40 

3.1 

23.1 

31.9 
8.9 

19.2 
2.6 
0.06 

14.50 
3.6 

17.3 

32.4 

Na20 

CaO 

13.1 
13.9 

MgO 

Fe203 

P2O5 

SO3 

1.9 

0.07 

11.40 

3.3 

CI 

21.7 

» Holt,  Courtney,  Fales:  Am.  Jour.  Dis.  Ch.  1915,  x,  229. 
*  Soldner:  From  Sommerfeld's  Handbuch,  etc.,  p.  800. 


HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY      121 

These  figures  show  that  the  ash  varies  in  amount,  as  well  as  other 
milk  components,  according  to  whether  the  sample  of  milk  is 
taken  at  the  beginning  or  at  the  end  of  nursing.  It  is  obviously 
just  as  necessary  to  obtain  milk  under  the  same  conditions  and 
with  the  same  precautions  when  the  salts  are  to  be  investigated 
as  when  the  other  food  components  are  to  be  studied. 

Calcium. — A  large  number  of  analyses  show  wide  individual 
variations  between  0.03  and  0.08%,  with  an  average  of  0.042  to 
0.044%.  The  daily  variations  may  amount  to  as  much  as  0.02%. 
The  calcium  content  decreases  as  the  period  of  lactation  pro- 
gresses. The  amount  of  calcium  cannot  be  increased  by  feeding 
the  mother  with  calcium  salts.  ^ 

Iron. — Friedjung  ^  found  from  3.52  to  7.21  mg.  iron  in  a  liter 
of  human  milk.  This  gives  an  average  of  5.09  mg.  This  figure  is 
somewhat  higher  than  those  given  by  Camerer  and  Soldner* 
and  Bahrdt  and  Edelstein,^  who  found  between  1.215  and  2.93  mg. 
per  liter.  The  iron  content  of  the  milk  is  dependent  on  the  general 
condition  of  the  woman.  It  is  higher  in  healthy  individuals  and 
lower  in  those  under  par.  A  regular  decrease  in  the  amount  of  iron 
during  lactation  has  not  been  demonstrated.  Neither  have  in- 
vestigations of  the  iron  content  of  the  milk  in  pathologic  condi- 
tions of  either  the  mother  or  the  baby  given  any  figures  of  clinical 
significance. 

Chlorids. — Freimd  ^  found  that  1,000  c.  c.  of  the  milk  of  the 
same  woman  contained,  on  four  successive  days:  0.488,  0498, 
0.433  and  0.456  NaCl.    Bunge  obtained  similar  results. 

Phosphorus. — There  is  a  great  difference  in  the  form  in  which 
phosphorus  is  present  in  human  and  in  cow's  milk.  Three-quarters 
of  that  in  human  milk  is  in  organic  combination,  while  only  one- 
quarter  of  the  phosphorus  in  cow's  milk  is  in  organic  combination. 
The  phosphorus  which  is  in  organic  combination  is  considered  by 
many  to  be  in  the  form  of  lecithin  and  nucleon,  which  are  present 
in  larger  amounts  in  human  than  in  cow's  milk  *  (see  lecithin  and 

^  Bahrdt  and  Edelstein:  Jahrb.  f.  Kinderh.,  1910,  Ixxii,  16;  Schabad:  Jahrb. 
f.  Kinderh.,  1911,  bodv,  511. 

*  Friedjung:  Arch.  f.  Kinderh.,  1901,  xxxii,  58;  JoUes  and  Friedjung:  Arch, 
f.  exper.  Path.  u.  Pharm.,  1901,  xlvi,  247  (entire  Uterature  to  date). 

3  Camerer  and  Soldner:  Ztschr.  f.  Biol.,  1900,  xxxix,  190;  1903,  xliv,  71; 
1905,  xlvi,  371. 

*  Bahrdt  and  Edelstein:  Ztschr.  f.  Kinderh.,  1910,  1,  182. 

*  Freund:  Chlor.  und  Stickstof  in  Sauglings  organisms,  Jahrb.  f.  Kinderh., 
1898,  N.  F.,  xlviii,  137. 

« Siegfried:  Ztschr.  f.  Phys.  Chem.,  1897,  xxii,  575;  Whittmaack:  Ztschr. 
f.  physiol.  Chem.,  1897,  xxii,  567;  Burow:  Ztschr.  physiol.  Chem.,  1900,  xxx, 
495. 


122      HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY 

nucleon);  41.5%  of  the  total  phosphorus  in  human  milk  is  in  the 
form  of  nucleon  phosphorus  and  only  6%  in  cow's  milk.*  Because 
of  the  larger  amount  of  casein  and  calcium  phosphate  which  it 
contains,  cow's  milk  is  much  richer  in  phosphorus  than  human 
milk.  The  relation  of  P2O5  to  N  is  1:54  in  human  milk,  and 
1 :27  in  cow's  milk.^  Keller  ^  found  that  one  liter  of  milk  con- 
tained of  P2O6 


Grams  P2O5; 
0.40 
0.44 
0.377 
0.452 
0.353 


n'lt^]  The  same  woman. 
The  mixed  mUk  of  different      "  •  -^^^  i 
wet-nurses. 


Sikes  ^  gives  0.297  P2O6  to  the  liter  as  an  average  of  figures  in 
the  first  three  weeks  of  life.  The  amount  varies  between  0,14  and 
0.522.  Schlossmann  ^  gives  as  an  average  0.461  P2O5  per  Hter. 
The  phosphorus  content  of  the  milk  depends  in  good  part  on  the 
casein  content  of  the  milk. 

Citric  Acid. — The  average  amount  of  citric  acid  in  huijian  milk 
is  0.05%.^ 

Caloric  Value. — The  caloric  value  of  one  Hter  of  human  milk  is 
782  calories.^ 

Unknown  or  Unidentified  Substances. — Meigs  and  Marsh  ^  re- 
port the  presence  of  substances  of  unknown  nature  which  contain 
little  or  no  nitrogen  and  are  soluble  in  alcohol  and  ether.  Human 
milk  immediately  after  the  colostrum  stage  contains  1%  of  these 
unknown  substances,  while  milk  from  the  middle  period  of  lacta- 
tion contains  about  0.5%;  cow's  milk  from  the  middle  period  of 
lactation  contains  about  0.3%  of  these  substances. 

Viscosity. — There  is  in  most  cases  a  regular  decrease  in  the 
viscosity  of  milk  during  the  first  twenty-four  hoiu^  postpartum. 
There  is  no  difference  between  the  viscosity  in  normal  or  abnormal 
cases  then  or  later.  The  electrical  conductivity  is  almost  always 
increased  in  abnormal  cases.  This  increase  is  least  when  there  is 
albuminuria  and  greatest  when  the  supply  of  milk  is  scanty.  There 
is  a  regular  decrease  in  the  electrical  conductivity  during  the  first 

'  See  note  6,  ante,  page  121. 

-  Schlossmann:  Arch.  f.  Kinderh.,  1905,  xl,  1, 

»  Keller:  Arch.  f.  Kinderh.,  1900,  xxix,  1. 

♦Sikes:  Jour.  Physiol.,  1906,  xxxiv,  464. 

*  Scheibe:  Quoted  by  Engel.    See  note  5,  p.  96. 

•Schlossmann:  Archiv.  f.  Kinderh.,  1900,  xxx,  288. 

^  Meigs  and  Marsh:  Jour,  of  Biol.  Chem.,  xvi.  No.  1. 


HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY      123 

week  postpartum.  ^    The  degree  of  viscosity  depends  on  the  amount 
of  solids  in  the  milk  especially  of  casein,^ 

VARIATIONS   IN   THE    COMPOSITION   OP   HUMAN   MILK 

Table  27,  page  112,  shows  the  lowest  and  highest  figures  given 
by  various  authors.  These  figures  show  that  the  variations  in  the 
percentage  of  fat  are  the  greatest,  but  that  there  are  considerable 
differences  in  the  percentages  of  the  other  components  of  human 
milk.  There  are  no  figures  in  Hterature  in  which  the  percentages 
of  all  components  are  high  or  all  low.  Usually,  when  one  com- 
ponent is  increased,  another  is  diminished. 

The  average  composition  of  human  milk  is  usually  given  as 
follows:  Fat,  4%;  lactose,  7%;  protein,  1.50%;  (casein  42%, 
filterable  nitrogen  including  lacatalbumin,  globulin  and  unknowm 
bodies  58%);  salts,  0.21%.  The  following  table  shows  the  varia- 
tion in  composition  during  the  different  periods  of  lactation. 

Pebcentaqe  Composition  of  Woman's  Milk  bt  Pbbioos  ' 


Period 

No.  of 
Analyaea 

Fat 

Sugar 

Protein 

Caaeiri 

Attnt' 
min 

Ash 

Total 
Solids 

Colostrum,  (1-12  da.) . . . 
Transition,  (12-30  da.) .  . 

Mature,  (1-9  mos.) 

Late.  (10-20  mos.) 

5 
6 
17 
10 

2.83 
4.37 
3.26 
3.16 

7.69 
7.74 
7.50 
7.47 

2.25 
1.56 
1.15 
1.07 

"a3 
.32 

"'.72 
.75 

.3077 
.2407 
.2062 
.1978 

13.42 
13.39 
12.16 
12.18 

The  previous  tables  show  that  human  milk  may  vary  widely  in 
its  composition  from  these  figures  and  still  be  normal. 

»  Polenaar  and  Phillipo:  Ztschr.  f.  Pathol.,  ix,  138. 

*Oertel:  Dissertation,  Leipzig,  1908,  Ref.  Arch.  f.  Kinderh.,  1909,  li,  282. 

» Holt,  Courtney  &  Fales:  Am.  Jour.  Dis.  Ch.,  1915,  x,  229. 


124      HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY 

TABLE  27 
Variations  in  Composition  op  Human  Milk  (prom  Czerny  and  Keller) 


Fat, 

Sugar, 

Protein,* 

Ash, 

Solids, 

per  cent. 

■per  cent. 

per  cent. 

per  cent. 

per  cent. 

Pf  eiffer  ^ 

0.75-9.05 

4.22-  7.65 

1.049-3.04 

0.104-0.446 

8.23-15.559 

Johannessen 

and  Wang  2. 
V.  and  J.  S. 

2.7  -4.6 

5.9  -  7.8 

0.9  -1.3 

Adriance '. . . 

1.31-7.61 

5.35-  7.95 

0.23  -2.60 

0.09  -0.28 

9.19-15.31 

Guirand  * 

1.75-6.18 

6.7  -  7.7 

0.85  -1.4 

0.10  -0.27 

11.2  -16.3 

Camerer  and 

Soldner  *. .  .  . 

1.28-5.77 

5.35-  7.52 

0.82  -1.86 

0.11  -0.36 

9.41-14.11 

Schlossmann  *. 

1.65-9.46 

5.2  -10.90 

0.56  -3.4 

*  Nitrogen  times  6.25. 

Influence  of  Food  on  Quantity  and  Composition  of  Milk. — 

The  fat  in  the  milk  may  diminish  when  the  mother  is  underfed.^ 
If  more  fat  is  given  in  the  diet  of  such  an  underfed  woman,  the 
fat  in  the  milk  will  increase  up  to  a  certain  point.  If,  however, 
large  amounts  of  fat  are  given  to  women  who  already  have  suffi- 
cient quantities  of  fat  in  the  food,  there  is  only  a  temporary  in- 
crease in  the  fat  in  the  milk  in  spite  of  the  excessive  fat  in  the  diet.* 
Czerny  and  Keller^  conclude  that  the  milk  of  nursing  mothers 
cannot  be  permanently  influenced  by  the  food,  except  in  those  in- 
stances in  which  they  do  not  get  sufficient  food,  i.  e.,  when  they 
are  partially  starved.  The  quantity  of  the  milk  cannot  be  in- 
creased at  will  by  increasing  the  amount  of  food  or  drink.  There 
are  a  few  instances  on  record  in  which  the  addition  of  sugar  to  the 
diet  of  a  nursing  woman  has  increased  the  amount  of  sugar  in  the 
milk.  Such  an  increase  is,  however,  by  no  means  the  rule  (see 
lactose). 

Hoobler  ^"  recently  studied  the  food  of  wet-nurses  to  determine 

iPf eiffer:  Verhandl.  d.  II  Vers.  d.  Gesellsch.  f.  Kinderh.  in  Wien,  1894, 
p.  131. 

2  Johannessen  and  Wang:  Ztschr.  f.  Physiol.  Chem.,  1898,  xxiv,  499. 

3  Adriance,  V.  and  J.  S. :  Arch,  of  Pediatrics,  1897,  xiv,  27. 
<  Guirand:  Th&se  de  Bordeaux,  1897. 

»  Camerer  and  Soldner:  Ztschr.  f.  Biol.,  xli,  N.  F.,  18,  p.  280. 

'Schlossmann:  Arch.  f.  Kinderh.,  1900,  xxx,  324. 

^  Engel  and  Plant:  Miinchen.  med.  Wochenschr.,  1906,  liii,  1158. 

*  Albert:  Ref.  Malys.  Jahresb.  f.  Thierchemie,  1899,  xxix,  253;  Henriques 
and  Hansen:  Jahresb.  f.  Thierchemie,  1899,  xxix,  68. 

8  Czerny  and  Keller:  Des  Kindes;  Emahrung,  Ernahrungsstorungen,  und 
Ernahrungstherapie,  Leipzig  and  Wien,  1906,  1,  407. 

10  Hoobler:  Am.  Jour.  Dis.  Ch.,  1917,  xiv,  105. 


HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY      125 

which  form  of  food  protein  was  the  most  economical  and  avail- 
able in  forming  milk  protein.  He  found  that  there  should  be  at 
least  one  part  of  food  protein  to  six  parts  of  food  carbohydrate, 
and  fats  for  the  best  production  of  milk.  He  also  found  that 
animal  protein  and  especially  that  from  milk  was  more  suitable 
than  vegetable  proteins,  in  supplying  nitrogen  for  milk.  A  diet 
of  fruits,  cereals,  and  vegetables  does  not  give  sufficient  available 
protein,  and  causes  a  severe  drain  on  the  tissues  of  the  mother. 
Nuts,  however,  added  to  this  diet  may  be  used  to  supply  the  deficit. 

GALACTAGOGUES 

Schafer  and  MacKenzie  *  found  that  the  posterior  lobe  of  the 
pituitary  body  of  the  ox  and  the  corpus  luteum  of  sheep  both  act 
as  galactogogues  when  injected  into  cats  and  dogs.  Hammond  ^ 
found  that  the  injection  of  pituitary  extract  into  lactating  goats 
increased  the  amount  of  milk  for  twenty-four  hours.  The  amount 
decreased  below  the  normal  during  the  next  twenty-four  hours, 
however,  so  that  the  average  of  the  two  days  was  the  normal 
amount.^  Gavin  did  not  find  the  pituitary  extract  affected  the 
quantity  of  milk  in  cows.  MacKenzie  and  others  ^  believe  that 
the  mammary  gland  can  be  stimulated  by  the  posterior  lobe  of  the 
pituitary  body,  the  pineal  body  and  the  corpus  luteum.  The  action 
of  the  former  is  supposed  to  be  the  most  powerful.  Inhibitory  sub- 
stances are  said  by  some  observers  to  be  produced  by  the  fetus, 
placenta,  spleen,  pancreas,  adrenals  and  thyroid.  Aschner  and 
Grigori,^  on  the  other  hand,  say  that  the  pulp  of  placenta  or  of 
the  fetus,  or  their  watery  extracts,  cause  a  true  secretion  of  milk 
in  virgin  animals,  and  that  the  body  which  causes  this  secretion  is 
(contrary  to  Starling's  contention)  destroyed  by  alcohol  and  heat. 
Basch®  reports  that  substances  present  in  the  placenta  when  in- 
jected into  animals  will  bring  back  the  secretion  of  milk  after  it 
has  stopped.  Hammett  and  McNeille  ^  recently  investigated  anew 
the  influence  of  ingested  dessicated  placenta  on  the  character  and 
secretion  of  human  milk  as  well  as  its  influence  on  the  growth  of 
the  infant.    It  is  not  apparent,  however,  that  the  changes  which 

*  Schafer  and  MacKenzie:  Proc.  Roy.  Soc,  London  (B),  1911,  bndv,  16. 

*  Hammond:  Quart.  Jour.  Exper.  Physiol.,  1913,  vi,  311. 
'Gavin:  Quart.  Jour.  Exper.  Physiol.,  1913,  vi,  13. 

*  MacKenzie:  Quart.  Jour.  Exper.  Physiol.,  1911,  iv,  305;  Ott  and  Scott: 
Therap.  Gaz.,  1911,  xxxv,  689.    (Experiments  on  goats.) 

'  Aschner  and  Grigori:  Arch.  Gyn.,  xciv.  No.  3.    (Guinea-pigs  were  used.) 
•Basch:  Munchen.  med.  Wochenschr.,  1911,  Iviii,  2266. 
'Hammett  and  McNeille:  Jour.  Biol.  Chem.,  1917,  xxx,  145. 


126      HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY 

they  attributed  to  its  use  were  any  greater  than  those  which 
might  be  normally  expected.  Wolf  ^  injected  milk  into  nursing 
women  and  found  that  there  was  an  increase  in  the  amount  of 
milk  secreted.  Chatin  and  Rendu  ^  repeated  Wolf's  work  with 
eight  women.  They  gave  thirteen  injections  of  milk  with  the  re- 
sult that  in  eight  instances  the  curve  of  milk  secretion  remained 
stationary  or  became  slightly  lowered.  In  the  five  remaining  in- 
stances, there  was  a  slight  increase  in  the  amount  of  milk  secreted 
after  the  injection  of  milk.  This  increase  was,  however,  always  in 
association  with  other  factors,  such  as  a  change  in  the  number  of 
nursings,  or  a  greater  demand  on  the  part  of  the  infant.  They  be- 
lieve that  the  latter  were  the  cause  of  the  increase  and  not  the 
former. 

There  is  much  evidence  to  show  that  substances  secreted  in  the 
ovary  cause  the  growth  of  the  breast  glands  at  puberty.  Cramer  * 
believes  that  it  has  no  influence  on  the  hyperplasia  of  pregnancy, 
while  Basch,*  on  the  other  hand,  attributes  the  increase  in  size  of 
the  breast  glands  to  a  secretion  in  the  ovary.  The  blood  of  a 
pregnant  animal  injected  into  a  lactating  animal  has  no  influence 
on  the  secretion  of  milk.^  After  summing  up  all  the  evidence  on 
the  subject,  one  is  forced  to  conclude  that  there  are  no  artificial 
means  of  increasing  the  secretion  of  milk. 

FOREIGN   BODIES   IN   HUMAN   MILK 

Certain  drugs  have  been  proved  to  be  excreted  in  human  milk 
after  they  have  been  taken  by  the  mother,  but  these  are  present 
only  in  traces.  They  are  potassium  iodid,  sodium  salicylate,  anti- 
pyrin,  mercury,^  aspirin,  calomel,  arsenic,  bromids,^  urotropin,* 
and  to  a  certain  extent  those  bodies  which  are  soluble  in  fat,  such 
as  the  iodinized  oils.®  Acetanilid  occasionally  appears  in  human 
milk  after  the  administration  of  a  dose  of  4  grains  in  from  seven 
to  fifteen  hours.  The  quantity  eliminated,  however,  is  so  minute 
as  to  be  harmless  to  the  nursing  infant.^ 

»  Wolf:  Zentralbl.  f.  Biochem.  u.  Biophys.,  1913,  xiv,  224. 

*  Chatin  and  Rendu:  Lyons  m^d.,  1912,  cxviii,  161. 

*  Cramer:  Mtinchen.  med.  Wochenschr.,  1909,  Ivi,  1521. 
*Basch:  Mtinchen.  Med.  Wochenschr.,  1911,  Iviii,  2266. 
'D'Errico:  La  Pediatria,  Abstr.  in  Jahrb.  f.  Kinderh.,  1910,  xxii,  504. 
*Engel:  In  Sommerf eld's  Handbuch  der  Milchkunde,  Wiesbaden,  1909, 

p.  810. 

^  Bucura:  Ztschr.  f.  Exper.  Path.  u.  Therap.,  1907,  iv,  398. 

*  Schmidt  and  Schroter:  Zentralbl.  f.  d.  ges.  Physiol,  u.  Path.  Stoffwechsels, 
1910,  V.  129;  Rieder:  Monatschr.  f.  Kinderh.,  1912,  xi,  80. 

*  Stevenson:  Mich.  State  Med.  Soc,  Jour.,  1914,  xiii,  p.  230. 


HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY      127 

Alcohol  is  found  in  human  and  cow's  milk  in  minimal  amounts 
after  the  ingestion  of  very  large  amounts,  but  not  after  the  taking 
of  small  amounts.*  It  is  possible  that  opium,  in  the  form  of  mor- 
phin,  and  atropin  may  be  excreted  in  human  milk,  since  it  has  been 
shown  that  they  go  over  into  the  milk  of  animals.^  They  have  not 
as  yet  been  found  in  human  milk. 

Salvarsan  injected  into  the  syphilitic  mother  is  excreted  in  the 
milk  and  after  such  treatment  the  syphilitic  suckling  frequently 
shows  remarkable  improvement;  in  some  instances  the  infant  has 
suddenly  died,  so  soon  after  the  institution  of  treatment  that  death 
seemed  to  result  from  trieatment.'  It  is  evident  that  such  treat- 
ment may  not  be  entirely  free  from  danger. 


INFLUENCE   OF  VARIOUS   PHYSIOLOGICAL  AND   PATHOLOGICAL   CON- 
DITIONS  ON   THE   SECRETION   OF   MILK 

Nervous  Impressions. — "Fright,  grief,  passion,  excessive  sexual 
indulgence,  or  any  great  excitement  may  entirely  arrest  the  secre- 
tion, or  if  not  arrested  the  milk  may  be  so  altered  in  composition 
as  to  make  the  child  actually  ill."  (Holt.)  Although  such  phe- 
nomena have  been  observed  chnically,  there  are  no  chemical  ob- 
servations which  tell  exactly  what  the  chemical  changes  are  under 
such  circumstances,  except  those  given  by  Rotch.^ 

Menstruation. — Rotch  ^  gives  the  illustration,  shown  in  the 
next  table  of  a  case  in  which  the  milk  was  examined  during  and 
after  menstruation. 

TABLE  28 
Effect  of  Menstruation  on  Breast-Milk 


Fat 

Lactose 

Protein 

Salts 

Water 

Second  day  of  menstrua- 
tion; chad's  stools  loose. 
Per  cent 

1.37 

2.02 
2.74 

6.10 

6.55 
6.35 

2.78 

2.12 
0.98 

0.15 

0.15 
0.14 

89.60 

Seven  days  after  menstru- 
ation;    bowels     regular. 
Per  cent 

89.16 

Forty  days  later;  child  gain- 
ing rapidly.    Per  cent. . . . 

89.79 

1  Voltz:  Biochem.  Ztschr.,  1913,  lii,  73. 

"  Czerny  and  Keller;  Des  Kindes  Emahrung,  Ernahrungsstorungen,  und 
Ernahrungstherapie,  Leipzig  and  Wein,  1906,  1,  407. 

*  Jesionek:  Munchen.  med.  Wochenschr.,  1911,  Iviii,  1169;  Jeanselme:  Ann. 
de  gyn6c.  et  d'obst.,  1911,  2  Ser.,  viii,  394;  Wolbarst:  Am.  Medicine,  1911, 
xvii,  486. 

*  Rotch:  Pediatrics,  Philadelphia  and  London,  1901,  p.  144. 


128      HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY 

Bendix  ^  examined  the  milk  of  eight  women  before,  during  and 
after  menstruation.  He  concluded  that  such  variations  as  he 
obtained  were  not  outside  of  the  normal  physiological  Umits. 

Grulee  and  Caldwell  ^  found  that  the  quantity  of  milk  varied 
with  menstruation.  There  was  a  period  of  increase  of  breast-milk 
commencing  with  the  first  day  of  menstruation  and  lasting  from 
that  day  to  two  weeks,  after  which  the  amount  diminished,  reach- 
ing its  lowest  point  four  to  seven  days  previous  to  the  next  men- 
strual period. 

Uremia. — Finizio  '  studied  the  protein  content  of  human  milk 
and  found  that  it  increased  only  in  nephritis  and  mild  uremia 
(see  residual  nitrogen).  Thiemich  ^  concluded,  after  reviewing  the 
Hterature,  that  this  increase  did  not  affect  the  nursing  infant  so 
long  as  the  quantity  of  the  milk  and  the  health  of  the  mother  were 
normal. 

Beriberi. — The  milk  of  mothers  with  beriberi  paralyzes  the 
heart  of  frogs  quicker  than  does  Ringer's  solution.  ^  Clinically, 
such  milk  is  dangerous  for  the  infant  and  causes  the  disease.  The 
poisons  are  said  to  be  toxins.  They  are  excreted  in  greater  quan- 
tities in  the  milk,  if  the  mother  is  constipated,^ 

Bile. — Bile  has  been  detected  in  the  fat  of  the  milk  of  a  patient 
who  developed  jaundice  after  each  confinement.  The  fat  con- 
tained urobilin  and  small  amounts  bilirubin,  while  there  were  no 
bile  components  in  the  aqueous  liquid.^ 

DIFFERENTIATION   OF   HUMAN   FROM    OTHER   MILKS 

Umikoff's  Reaction. — When  5  c.  c.  of  milk  are  warmed  on  a 
water  bath  at  60  C.  with  2.5  c.  c.  of  a  10%  solution  of  ammonium 
hydrate  for  from  fifteen  to  twenty  minutes,  a  reddish  violet  color 
appears  if  human  milk  is  used,  while  there  is  no  change  with  cow's 
milk. 

Davidsohn's  Reaction. — See  fat-splitting  ferment. 

Moro's  Reaction.^ — Moro  found  that  a  1%  aqueous  solution  of 
neutral  red  turns  human  milk  yellow  and  cow's  milk  purple.    The 

1  Bendix:  Charit6-Aim.,  1898,  xxiii,  412;  Baueberg:  Zeitschr.  f.  Kinderh., 
1913,  vi,  424. 

2  Grulee  and  Caldwell:  Am.  Jour.  Dis.  Ch.,  1915,  ix,  374. 

3  Finizio:  Pediatria,  1908,  vi,  401. 

*  Thiemich:  Monatschr.  f.  Geburtsch.  u.  Gynak.,  viii,  521;  ix,  504. 

*  Guerrero  and  Cavieres:  Bull.  Manila  Med.  Soc,  1912,  iv,  167. 

*  Inagaki  and  Nakayama:  Abstr.  in  Brit.  Jour.  Dis.  Child.,  1910,  vii,  467. 
^  Marck:  Pharm.  Weekblad.,  1907,  xliv,  153. 

*Moro:  Milnchen.  med.  Wochenschr.,  1912,  lix,  2553. 


HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY      129 

addition  of  one  drop  of  the  stain  to  a  teaspoonful  of  drawn  breast- 
milk  changes  it  to  a  reddish  purple  at  once,  if  the  milk  has  been 
kept  too  long  and  is  unjfit  for  use. 

Bauer's  Reaction.^ — Bauer  found  that  the  addition  of  one  drop 
of  a  0.25%  aqueous  solution  of  neutral  blue  sulphate  (Grubler)  to 
from  2  to  3  c.  c.  of  human  milk  turns  the  milk  violet-blue.  When 
added  to  cow's  milk  it  turns  it  greenish-blue.  When  about  five 
times  as  much  ether  is  added  and  the  mixture  is  shaken  violently, 
the  color  is  extracted  from  human  milk  but  persists  in  cow's 
milk. 

Tugendreich's  Reaction.^ — Equal  amounts  of  a  1  to  2%  aqueous 
solution  of  silver  nitrate  and  milk  are  mixed,  shaken  and  quickly 
boiled  for  three  minutes.  Human  milk  changes  in  color  to  coffee- 
brown  or  brownish-violet,  while  cow's  milk  does  not. 

FERMENTS    (eNZYMEs) 

A  great  deal  of  importance  has  been  attached  to  the  ferments 
or  enzymes  of  milk,  especially  in  the  discussions  as  to  whether 
raw  or  boiled  milk  is  the  more  digestible  for  infants  and  in  con- 
nection with  the  diseases  of  metabolism,  such  as  scorbutus  and 
rachitis. 

The  study  of  the  ferments  is  open  to  error  because  of  the  pres- 
ence of  bacteria  in  milk.  It  is  almost  impossible  to  obtain  a 
truly  sterile  milk  and  to  keep  that  milk  sterile  for  any  length  of 
time.  The  use  of  toluol  or  chloroform  to  keep  the  milk  sterile  may 
modify  or  destroy  the  enzymes,  while  steriUzation  by  heat  de- 
stroys the  enzymes.  Since  the  action  of  bacteria  may  cause  all  the 
phenomena  produced  by  the  ferments  in  milk,  the  action  of  bac- 
teria must  always  be  excluded. 

The  Proteolytic  Ferments. — (a)  Casease  has  the  property  of 
converting  casein  into  soluble  albumin.^  It  is  foimd  in  hiunan  and 
cow's  milk. 

(b)  Pespin  and  Tryspin:  Both  of  these  ferments  are  supposed  to 
be  present  in  cow's  and  human  milk  (Spolverini  *),  the  one  acting 
in  acid  media  and  the  other  in  alkaline  surroundings.  Other  in- 
vestigators ^  could  not  convince  themselves  that  there  were  any 
such  ferments  in  demonstrable  quantities.    The  proteolytic  fer- 

1  Bauer:  Monatschr,  f,  Kinderh.,  1912-13,  orig.  xi,  474. 

*  Tugendreich:  Berl.  klin.  Wochenschr.,  1911,  xlviii,  No.  1,  p.  224. 
'Raudnitz:  Ergebn.  d.  Physiol.,  1903,  ii. 

*  Spolverini:  Arch,  de  m6d.  d.  Enf.,  1901,  iv,  705. 

«  Moro:  Jahrb.  f.  Kinderh.,  1902,  N.  F.,  Ivi,  391;  Hippius:  Jahrb.  f.  Kinderh., 
1905,  bd,  365. 


130      HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY 

ments,  according  to  Freeman  ^  are  not  affected  by  heating  for  one- 
half  hour  at  65  C.  (149  F.)  or  for  one  hour  at  60  C.  (140  F.)  They 
are  destroyed  by  boiling. 

(c)  Fibrinogen :  Schlossmann  ^  observed  that  human  milk  caused 
the  coagulation  of  the  hydrocele  fluid  from  a  young  infant,  while 
cow's  milk  did  not.  This  observation  was  subsequently  con- 
firmed.^ It  was  shown  that  this  ferment  is  not  destroyed  by  heat  ^ 
and  that  it  is  sometimes  found  in  cow's  milk.^ 

Carbohydrate-Splitting  Ferments. — Amylase  ®  has  the  power  of 
splitting  starch  into  dextrin  and  of  continuing  the  process  until  a 
very  Uttle  of  it  is  converted  into  maltose.^  This  ferment  is  pres- 
ent in  human  milk.  According  to  some  investigators  it  is  not 
present  in  cow's  milk.  Others  ^  using  different  methods,  always 
find  it  in  cow's  milk.  The  action  of  amylase  is  increased  by  the 
addition  of  peroxid  of  hydrogen.^  It  is  destroyed  at  the  tem- 
perature of  75  C.  (167  F.),  perhaps  at  a  somewhat  lower 
one.  It  appears  to  pass  into  the  whey  when  the  casein  is 
precipitated. 

A  disaccharid-splitting  ferment  has  been  reported  in  cow's  milk 
which  is  capable  of  spUtting  lactose;  it  may  also  be  present  in 
human  milk.^°  It  is  not  changed  by  heating  for  one-half  an  hour 
at  65  C.  (149  F.)  or  for  one  hour  at  60  C.  (140  F.),  but  is  weakened 
by  heating  for  a  short  time  at  70  C.  (158  F.)  and  is  destroyed  at 
75  C.  (167  F.)." 

Fat-Splitting  Ferment. — This  ferment  decomposes  neutral  fats 
into  fatty  acids  and  glycerin. ^^  It  is  found  in  both  human  and 
cow's  milk.  This  ferment  in  human  milk  breaks  tributyrin  inta 
butyric  acid  in  a  very  few  minutes,  but  in  cow's  milk  only  after 
many  hours.  This  test  may  be  used  to  differentiate  raw  human 
milk  from  boiled  human  milk,  and  raw  and  boiled  cow's  milk.^* 

^  Freeman:  Jour.  Am.  Med.  Assn.,  1907,  xlix,  1740. 

*  Schlossmann:  Verhandl.  d.  xviii  Versamml.  Gesellsch.  f.  Kinderh.,  Ham- 
burg, 1901. 

'  Moro:  Wien.  klin.  Wochenschr.,  1902,  xv,  121. 

*  Moro  and  Hamburger:  Wien.  klin.  Wochenschr.,  1902,  xv,  121. 
6  Bernheim-Karrer:  Zentralbl.  f.  Bakt.,  1902,  xxxi,  388. 

'  Diastase,  zymase,  diastatic  ferment. 

^  Bechamp:  Compt.  rend.,  Acad.  d.  sc,  1883,  96. 

^Konig:  Milch wirtschol:  Zentralbl.,   1907,  iii. 

'Lagane:  Compt.  rend.,  Acad.  d.  sc,  156,  1941. 
loStoklasa:  Arch.  f.  Hyg.,  1904,  1,  165. 
"Freeman:  Jour.  Am.  Med.  Assn.,  1907,  xliv,  1740. 

"  Marfan  and  Gillet:  Monatschr.  f.  Kinderh.,  1902-3,  1,  57;  M  Uk.  eU.,. 
note  3);  Hippius  (toe.  cit.,  page  117). 

"Davidsohn:  Ztschr.  f.  Kinderh.,  1913,  viii,  14. 


HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY      131 

The  ferment  is,  therefore,  present  in  relatively  large  amounts  in 
human  milk,  but  only  in  traces  in  cow's  milk.  Heating  to 
60  C.  (140  F.)  does  not  affect  it,  while  64  C.  (147.2  F.)  de- 
stroys it. 

Salol-Splitting  Ferment. — It  was  foimd  that  human  milk  had 
the  power  of  sphtting  salol.  This  power  was  not  destroyed  by 
heating  to  100  C.  (212  F.).  Further  investigation  showed  that  this 
phenomenon  was  not  due  to  a  ferment,  but  was  purely  chemical. 
Salol  is  split  in  an  alkaline  medium  of  the  same  alkalinity  as  human 
milk.  When  cow's  milk  is  brought  to  the  same  grade  of  alkalinity 
it  also  will  split  salol.  ^ 

Oxydase  and  Reductase. — (a)  Super  oxidase:  Superoxidase  is 
the  name  given  to  the  ferment  which  reduces  peroxid  of  hydrogen 
into  water  and  oxygen.  It  acts  best  at  about  37  C.  (98.6  F.)  and  is 
destroyed  at  about  68  C.  (154.4  F.).  During  centrifugalization  it 
rises  with  the  cream.^  There  is  a  large  amoimt  both  in  human  milk 
and  cow's  milk. 

(b)  Peroxidases:  Peroxidases  hasten  the  oxidation  of  such  bodies 
as  tincture  of  guaiac.  They  pass  into  the  cream  during  centrifugaU- 
zation  and  in  fractional  precipitation  are  precipitated  along  with 
the  globulins.'  There  is  no  definite  temperature  at  which  this 
enzyme  is  destroyed,  because  the  rate  of  heating  modifies  the 
results.'* 

(c)  Reductase:  When  reductase  comes  in  contact  with  sulphur 
and  water  it  converts  the  sulphurin  to  the  corresponding  hydrids;  * 
it  also  reduces  methylene  blue  ®  and  decolorizes  Schardinger's 
reagent.^  It  is  stronger  in  cream  than  in  skimmed  milk  ^  and  is 
precipitated  with  the  casein.  It  is  found  in  both  human  and  cow's 
milk.  Its  action  with  Schardinger's  reagent  *  is  used  in  differen- 
tiating raw  from  boiled  milk.  Heating  milk  to  between  70  C. 
(158  F.)  and  80  C.  (176  F.)  stops  the  reaction.  Reductase  is  most 
active  between  40  C.  (104  F.)  and  55  C.  (131  F.). 

^  Demoulieres:  Jour,  de  pharm.  et  chim.,  1903,  xvii,  Miele  and  Willen: 
Compt.  rend.,  Acad.  d.  sc,  1903,  cxxxvii. 

2  Hecht  and  Friedjung:  Arch.  f.  Kinderh.,  1903,  xxxvii,  177. 

'Raundnitz:  Pfaundler  and  Schlossmann:  Diseases  of  Children,  Philadel- 
phia and  London,  1908,  i,  308. 

*  Van  Eck:  Chem.  Weckblad,  viii,  692,  ref.  Chem.  Abstr.,  Jan.  10,  1912. 

'  Rey:  Pailhade  quoted  from  Possi-Escot:  Etat  actuel  sur  les  oxydases  et 
reductases,  Paris,  1902. 

'  Possi-Escot  (see  note  8,  page  118). 

'  Smidt:  Hyg.  Rundschau,  1904,  xiv,  1137;  Hecht:  Arch.  f.  Kinderh.,  1904, 
xxxviii,  349. 

'  Five  c.  c.  saturated  alcohol  solution  of  methylene  blue,  6  c.  c.  formalin, 
190  c.  c.  water. 


132      HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY 

TRANSMISSION  OF  TOXIC  BODIES  AND  IMMUNITY  THROUGH  MILK 

Toxins. — Sonnenberger  ^  concluded  from  his  investigations  that 
milk  is  not  only  a  secretion  but  an  excretion  and  that,  therefore, 
many  vegetable  poisons  in  the  food  of  animals  may  go  over  in 
the  milk.  Among  these  poisons  are  alkaloids,  glycosids  and 
amids,  as  well  as  volatile  and  ethereal  oils,  and  dibasic  organic 
acids. 

Toxins  may  be  formed  as  the  result  of  the  metabolism  of  certain 
bacteria,  may  be  produced  by  plants,  or  may  come  from  the 
secretions  or  body  components  of  certain  animals. 

Antibodies. — Ehrlich  ^  was  the  first  to  show  that  immunity 
could  be  transmitted  to  the  infant  through  the  milk.  The  fact  that 
breast-fed  infants  seem  to  be  less  liable  to  such  diseases  as  measles, 
scarlet  fever,  mumps  and  typhoid  fever  is  used  by  many  as  an 
argument  that  immunity  is  transmitted  through  the  breast- 
milk.  Recently  emphasis  has  again  been  laid  on  the  greater  im- 
munity of  the  breast-fed  infant  to  infection,  than  the  artificially- 
fed.5 

Antitoxin. — It  has  been  shown  that  in  animals  immunity  to 
the  bacillus  of  anthrax  and  the  pneumococcus  is  transmitted  by  the 
mother  to  the  young.  It  is  impossible  to  say,  however,  whether 
this  immunity  is  transmitted  through  the  milk  or  is  acquired  dur- 
ing intrauterine  life.^  Ehrlich  ^  concluded  from  his  researches  that 
artificial  immunity  can  only  come  through  the  milk  of  the  mother. 
When  a  mouse  which  was  bom  of  a  normal  mother,  which  was  not 
immunized,  was  fed  by  a  mouse  immimized  with  antitoxin,  the 
suckling  developed  immunity.  The  amount  of  antitoxin  that 
passes  from  the  mother  through  the  milk  to  the  suckling  is  between 
one-fifteenth  and  one-thirtieth  of  the  total  amount  in  the  mother, 
depending  on  the  amount  of  lactalbumin  and  globulin  that  her 
milk  contains.^  It  was  impossible  to  immunize  the  human  infant 
by  feeding  it  with  horse  antitoxin,  but  when  its  own  mother  or  the 
wet-nurse  was  immunized  with  horse  antitoxin  the  immunity  was 

^  Sonnenberger:  Therap.  Monatschr.,  1901,  xv,  6;  Sonnenberger:  bcxi 
Naturforschersamml.,  Miinchen,  1899. 

2  Ehrlich:  Ztschr.  f.  Hyg.  u.  Infectionskr.,  1892,  xii,  183. 

'  Kleinschmidt:  Monatschr.  f.  Kinder.,  1913,  xii,  423;  Czemy,  Med.  Klinic, 
1913,  vii,  895. 

*  Chauveau:  Ann.  de  I'lnst.  Pasteur,  1888,  ii,  66;  Klemperer:  Arch.  f.  Exper. 
Pathol,  u.  Pharm.,  1892-93,  xxxi,  356. 

*  Brieger  and  Ehrlich:  Ztschr.  f.  Hyg.,  1893,  xiii,  336;  Brieger  and  Cohn: 
Ztschr.  f.  Hyg.,  1893,  xv,  1;  Wassermann:  Ztschr.  f.  Hyg.,  xviii;  Ehrlich  and 
Wassermann:  Ztschr.  f.  Hyg.,  1894,  xviii,  235;  Romer:  Berl.  klin.  Wochenschr., 
1901,  xlvi,  209;  Kayser:  Ztschr.  f.  klin.  Med.,  1905,  Ivi,  17. 


HUMAN  MILK,  CHEMISTRY  AND  BIOLOGY      133 

transferred  through  the  milk  to  the  nursing  infant  even  as  early  as 
the  fourth  week  of  life.^  Immunity  can,  therefore,  be  transferred 
by  way  of  the  milk  or  albumins  of  the  same  species,  but  not  by 
those  of  another  species. 

Agglutinins. — The  same  question  comes  up  in  studying  the 
agglutinins  as  in  the  case  of  the  antitoxins  as  to  whether  the 
property  of  agglutination  is  acquired  during  intrauterine  life  or 
passes  through  the  milk. 

The  evidence  that  it  may  be  transferred  by  the  mother  through 
her  milk  to  the  infant  is  in  part  positive  and  in  part  negative. 
Romer,^  after  summing  up  the  Uterature,  concludes  that  agglu- 
tinins may  be  transferred  in  the  milk.  The  agglutinins  in  the  milk 
of  the  mother  are  more  easily  absorbed  from  the  infant's  gastroin- 
testinal canal  than  those  in  the  milk  of  animals. 

Bactericidal  Substances. — The  fact  that  the  blood  of  infants 
that  are  nursed  at  the  breast  contains  stronger  bactericidal  sub- 
stances than  that  of  those  fed  on  the  bottle  ^  is  evidence  in  favor  of 
these  substances  being  carried  in  the  milk,  in  spite  of  the  fact  that 
they  cannot  be  demonstrated  in  the  milk  itself. 

Hemolysin. — Hemolysin  has  recently  been  demonstrated  as  a 
normal  constituent  of  the  different  kinds  of  milk.*  It  is  absent 
from  colostrum  in  the  majority  of  cases  tested  on  the  second  day 
postpartum.^  Hemagglutinins  are  found  in  human  milk  that 
react  differently  toward  the  blood  corpuscles  of  different  species  of 
animals.^ 

Opsonin. — The  milk  is  poorer  in  opsonins  than  the  blood  serum 
of  the  mother''  while  the  colostrum  contains  more  than  the 
milk.^ 

Hjrpersensibility. — Hypersensibility  (sensitization)  toward  va- 
rious poisons  and  albumins  may  pass  over  in  the  milk  to  the  infant 
and  be  absorbed.^ 

» Salge:  Jahrb.  f.  Kinderh.,  1904,  Ix,  1. 

*Romer:  Soramerf eld's  Handbuch  der  Milchkimde,  Wiesbaden,  1909,  492. 
'Moro:  Jahrb.  f.  Kinderh.,  1902,  Iv,  396. 

*  Pfaundler  and  Moro:  Ztschr.  f.  Exper.  Pathol,  u.  Therap.,  1907,  iv,  451. 
5  Kolff  and  Noeggerath:  Jahrb.  f.  Kinderh.,  1909,  Ixx,  701. 
« Zubezycki  and  Wolfsgruber:  Deutsch.  med.  Wochenschr.,   1913,  xxxix, 
210. 

^  Turton  and  Appleton :  Reference,  Deutsch.  med.  Wochenschr.,  1907,  xxxiv. 

«TunnicliflF:  Jour.  Infect.  Dis.,  1912,  xi,  347. 

'Otto:  Miinchen.  med.  Wochenschr.,  1907,  Uv,  1665. 


CHAPTER  XI 
CIJNICAL   CONSIDERATIONS   AND   TECHNIQUE 

The  contraindications  to  nursing  have  already  been  mentioned, 
and  the  abihty  of  women  in  general  to  nurse  their  babies  has  al- 
ready been  referred  to.  Far  more  women  are  able  to  nurse  their 
babies  than  is  generally  supposed.  As  a  matter  of  fact,  very  few 
women  are  entirely  unable  to  nurse.  The  so-called  inability  to 
nurse  is  in  many  instances  unwillingness  rather  than  inability. 
Many  women  are,  however,  thought  to  be  unable  to  nurse  when 
they  really  are  able.  The  attempt  at  nursing  is  not  infrequently 
given  up  too  soon  because  the  milk  is  late  iir  appearing.  The 
production  of  milk  begins  in  two  ways:  either  the  quantity  of  milk 
slowly,  but  gradually,  increases  or,  after  a  very  small  secretion  in 
the  beginning,  there  is  a  very  sudden  increase,  which  is  often 
spoken  of  as  the  "running-in"  of  the  milk.  The  supply  of  milk  is 
often  considered  insufficient  when  the  "running-in"  is  delayed, 
and  breast  feeding  is  therefore  considered  impossible.  Dluski's 
figures  ^  show  how  different  the  time  of  the  "running-in"  of  the 
milk  may  be.  She  found  that  in  326  primiparse  the  running-in 
of  the  milk  occurred  as  follows:  9  times  after  24  to  48  hours,  115 
times  after  48  to  72  hours,  159  times  after  72  to  96  hours,  42  times 
after  96  to  120  hours,  one  time  after  120  to  144  hours.  The  best 
method  of  hastening  the  appearance  of  the  milk  is  by  emptying 
the  breasts  as  completely  as  possible.  The  best  way  to  do  this 
is  by  putting  an  older  and  stronger  infant  to  the  breast.  The 
older  infant  not  only  sucks  more  strongly,  but  does  not  get  as  tired 
as  the  younger  child,  who  often  refuses  to  nurse  after  a  few  at- 
tempts, if  the  milk  does  not  flow  easily.  If  an  older  baby  cannot 
be  obtained,  the  mother's  own  infant  may  be  used. 

The  supply  of  milk  is  not  infrequently  insufficient  while  the 
mother  is  in  bed,  and  nursing  is  on  this  account  given  up.  It  is  not 
uncommon,  however,  to  have  the  supply  of  milk  increase  and  be 
amply  sufficient  after  the  mother  is  able  to  be  out  of  bed  and  to 
take  up  her  ordinary  routine. 

It  is  sometimes  thought  that  it  is  not  worth  while  for  a  woman  to 
nurse  her  baby  unless  she  can  nurse  it  for  a  considerable  time. 
1  Thfise  de  Paris,  1894. 
134 


NURSING  A  PHYSIOLOGICAL  CONDITION       135 

This  belief  is,  of  course,  entirely  erroneous,  because  there  is  no  time 
in  a  baby's  life  at  which  it  is  more  important  for  it  to  have  breast- 
milk  than  in  the  beginning.  There  is  no  time  at  which  a  baby's 
digestion  is  so  easily  disturbed  and  so  hard  to  correct,  if  disturbed, 
as  in  the  early  days  and  weeks  of  Ufe.  Every  day  or  week  that  a 
baby  gets  breast-milk  gives  it  a  better  start  and  makes  it  easier  to 
put  it  on  an  artificial  food  later,  if  it  is  necessary.  It  is  also  some- 
times thought  that  it  is  hardly  worth  while  to  give  a  baby  the 
breast,  unless  it  can  get  all  its  food  from  the  breast.  Others  beUeve 
that  it  is  dangerous  to  mix  himian  milk  and  artificial  food.  This 
belief  is,  of  course,  entirely  erroneous.  The  artificial  food  cannot 
make  the  breast-milk  harder  of  digestion,  while  the  breast-milk 
clinically  certainly  seems  to  make  the  digestion  of  the  artificial 
food  easier.  Every  Httle  bit  of  breast-milk  helps  the  baby  and 
makes  it  easier  to  feed  it  artificially.  This  may  be  due  in  part  to  the 
ferments  which  the  breast-milk  contains,  but  more  probably  is  due 
to  the  fact  that  the  baby  is  able  to  utilize  the  proteins  of  human 
milk  to  build  tissues,  when  it  is  not  able  to  utihze  the  proteins  of  the 
artificial  food  in  the  same  way. 

Nursing  is  sometimes  given  up  almost  at  once  because  of  poor 
nipples  or  cracked  nipples.  Nursing  should  not  be  given  up  for 
these  reasons  until  strenuous  attempts  have  been  made  to  draw  out 
the  nipples  or  to  have  the  baby  nurse  with  a  nipple-shield .  Cracked 
nipples  will  almost  invariably  heal  if  time  and  trouble  enough  are 
taken. 

In  other  cases  nursing  is  not  attempted  because  it  is  feared  that 
the  strain  of  nursing  will  be  too  great  for  the  health  of  the  mother. 
It  is  true  that  in  some  instances  nursing  does  pull  down  the  mother 
materially.  It  must  not  be  forgotten,  however,  that  nursing  is  a 
physiological  and  not  a  pathological  condition,  and  that  many 
women  are  better  while  nursing  than  at  any  other  time.  Even  if  it 
does  pull  a  woman  down,  however,  a  mother  should  be  willing  to 
sacrifice  herself  to  a  certain  extent  in  order  to  give  the  baby  a  good 
start.  A  few  weeks  or  a  few  months  of  nursing  will  make  all  the 
difference  to  the  baby  in  the  future.  It  is  often  said  that  women 
are  too  nervous  to  nurse,  that  their  mUk  will  be  bad  on  this  account 
and  that  the  baby  will  be  disturbed  and  will  not  thrive.  This  is 
undoubtedly  true  in  a  certain  number  of  instances.  Other  women, 
however,  apparently  as  imsuitable  for  nursing,  prove  to  be  very 
good  nurses.  On  this  account,  therefore,  nursing  should  always  be 
attempted,  to  be  given  up  later  if  it  is  not  successful. 

In  general,  women  are  altogether  too  prone  to  believe  on  in- 
siifficient  grounds  that  they  cannot  nurse  their  babies.    It  is  sad  to 


136  FEEDING  IN  THE  FIRST  FEW  DAYS 

say  that  they  are  often  aided  and  abetted  in  this  belief  by  physi- 
cians and  nurses,  who  should  know  better.  It  is  a  hopeful  fact, 
however,  that  the  women  among  the  well-to-do  and  educated 
classes  are  beginning  to  appreciate  the  importance  of  breast  feeding 
and  that  many  more  of  them  are  not  only  willing  but  anxious  to 
nurse  than  were  a  few  years  ago. 

Feeding  in  the  First  Few  Days  of  Life. — ^The  baby  should  be 
put  to  the  breast  from  six  to  twelve  hours  after  birth,  according 
to  the  condition  of  the  mother  and  the  strength  of  the  baby.  The 
object  of  putting  the  baby  to  the  breast  at  this  time  is  not  to  give 
the  baby  food,  but  to  stimulate  the  breast  to  secretion.  It  is 
supposed  that  nursing  also  favors  the  involution  of  the  uterus. 
There  is,  however,  no  positive  proof  that  this  is  so.  The  baby 
should  be  put  to  the  breast  every  six  hours  during  the  next  twenty- 
four  hours,  and  every  four  hours  during  the  succeeding  twenty- 
four  hours.  With  the  appearance  of  the  milk,  the  interval  may 
then  be  shortened.  The  average  amount  of  colostrum  obtained 
during  the  first  twenty-four  hours  is  from  4  to  6  c.  c,  and  during 
the  second  twenty-four  hours,  90  c.  c.  In  the  majority  of  cases  the 
milk  then  comes  in  rapidly  on  the  third  and  fourth  days.  In  many 
instances,  however,  the  milk  does  not  come  in  until  a  day  or  two 
later  than  this.  It  is  evident  from  the  small  amount  of  colostrum 
secreted  during  the  first  two  or  three  days  that  the  baby  is  not 
intended  by  nature  to  get  much  food  during  this  time.  Further 
proof  of  this  fact  is  that  the  initial  loss  of  weight  is  not  prevented 
by  feeding  larger  amounts  of  food  from  the  beginning.  It  is  well, 
however,  to  give  the  baby  water  freely  in  order  to  flush  out  the 
kidneys  and  make  up  for  the  water  lost  in  other  ways.  One  or  two 
drachms  should  be  given  every  two  hours,  more  often  if  the  baby 
wishes  it  and  will  take  it.  It  is  often  advisable  to  give  a  solution 
of  milk  sugar  and  water  at  this  time  in  order  to  favor  the  develop- 
ment of  the  normal  bacterial  flora.  There  is  no  proof,  however, 
as  to  whether  this  is  accomplished  or  not.  Some  beUeve  that  sugar 
at  this  time  does  harm,  but  there  is  no  proof  whether  it  does  or  not. 
It  is  probably,  however,  better  on  the  whole  to  give  a  mixture  of 
saccharin  and  water  than  sugar  and  water. 

Most  babies  begin  to  show  signs  of  hunger  after  the  first  forty- 
eight  hours.  It  must  be  remembered,  however,  that  crying  at  this 
time  does  not  necessarily  mean  hunger,  because  every  new-bom 
baby  cries  a  certain  amount.  It  is  wiser  to  begin  to  give  some  food 
on  the  third  day,  if  the  supply  of  breast-milk  is  insufiicient.  It  is 
not  necessary  to  begin  to  feed  them  at  this  time,  however,  as 
experience  has  shown  conclusively  that  it  does  the  baby  no  harm 


FEEDING  IN  THE  FIRST  FEW  DAYS  137 

to  go  four  or  five  days  without  food.  It  is  very  important,  when 
beginning  to  feed  a  new-born  baby,  not  to  give  it  too  much  food 
or  too  strong  a  food.  There  is  no  time  m  a  baby's  life  in  which  it  is 
so  easy  to  disturb  the  digestion  or  at  which  it  is  so  diflScult  to  cor- 
rect the  disturbance,  if  it  is  once  caused.  If  the  baby  is  put  to  a 
breast  whose  secretion  is  already  estabUshed,  there  is  great  danger 
that  it  will  take  too  much  food  and  be  disturbed  by  it.  The  dura- 
tion of  nursing  must,  therefore,  be  very  short  in  the  beginning. 
It  is  often  wiser  to  give  breast-milk  diluted  with  water  from  a 
bottle  for  one  or  two  days  before  putting  the  baby  to  the 
breast.  It  is  probable,  too,  that  the  baby  digests  breast-milk 
better  if  it  has  had  colostrum  first.  There  is,  however,  no  proof 
of  this. 

If  the  baby  has  to  be  given  an  artificial  food,  it  is  very  important 
not  to  give  it  too  strong  a  mixture.  It  is  absolutely  wrong  to  say, 
as  many  physicians  do,  "Give  it  a  little  milk  and  water.  It  is  not 
necessary  to  give  it  a  mixture  at  this  time,  because  it  will  be  on  the 
breast  in  a  few  days."  The  digestion  is  so  easily  disturbed  at  this 
time  that  there  is  no  time  at  which  it  is  more  important  to  give  a 
mixture  suited  to  the  baby.  It  is  very  important  to  begin  with  a 
weak  mixture  and  to  give  it  in  small  amounts.  If  this  mixture  is 
digested  and  the  baby  is  still  hungry,  it  is  very  easy  to  increase 
the  strength  and  the  amount  of  the  food.  If  the  baby  is  upset  by 
too  strong  a  food,  it  is  a  very  difficult  matter  to  correct  the  dis- 
turbance. The  mixture  should  be  low  in  fat  and  proteins,  which 
are  relatively  hard  to  digest,  and  proportionally  high  in  sugar, 
which  is  easy  of  digestion  at  this  time.  It  is  wise,  also,  to  give  a 
part  of  the  proteins  in  the  form  of  the  whey  proteins.  A  suitable 
mixture  is  fat  1%,  milk  sugar  5%,  whey  proteins  0.25%,  casein 
0.25%.  This  may  be  quickly  strengthened,  perhaps  in  the  first 
twenty-four  hours,  to  fat  1.50%,  sugar  6%,  whey  proteins  0.50%, 
casein  0.25%,  and  then  in  another  twenty-four  hours  to  fat  2%, 
sugar  6%,  whey  proteins  0.75%  and  casein  0.25%.  Two  drachms 
(10  c.  c.)  is  enough  at  first.  This  can  be  quickly  increased  to  one- 
half  to  one  ounce  (15  or  30  c.  c). 

The  colostrum  is  supposed  to  have  a  laxative  action.  Such  an 
action,  however,  has  not  been  proven.  If  the  bowels  have  not 
moved  well  during  birth  or  during  the  first  twenty-four  hours,  it 
is  wise  to  give  a  teaspoonful  of  castor  oil  in  order  to  empty  them, 
because  of  the  possible  danger  of  the  absorption  of  the  products  of 
decomposition  of  retained  meconium.  It  is  probable  that  these 
products  may  cause  convulsions  and  other  severe  nervous  symp- 
toms, as  well  as  fever  and  marked  prostration.    At  any  rate,  such 


138  REGULARITY  OF  NURSING 

sjanptoms  in  the  new-bom  are  repeatedly  relieved  by  the  empty- 
ing of  the  intestinal  tract. ^ 

Intervals  between  Nursings. — There  is  much  difference  of  opin- 
ion as  to  the  proper  intervals  between  nursings.  This  subject 
will  be  discussed  later  in  detail  in  the  chapter  on  artificial  feeding. 

Regularity  of  Nursing. — ^Whatever  intervals  between  nursings 
are  adopted,  the  baby  should  be  nursed  regularly  at  these  intervals. 
There  is,  of  course,  no  doubt  that  many  babies  thrive  in  spite  of 
being  nursed  at  any  and  all  times.  On  the  average,  however,  babies 
do  better  when  they  are  fed  regularly.  A  baby  quickly  accommo- 
dates itself  to  being  fed  at  regular  intervals  and  soon  learns  to 
expect  to  be  fed  at  these  times  and  not  at  others.  The  mother, 
moreover,  can  arrange  her  time  much  better,  if  she  knows  when  the 
baby  is  to  be  fed.  It  is  very  difficult  for  the  modem  woman,  who 
has  many  other  legitimate  demands  upon  her  time,  to  always  be 
on  hand  at  the  nursing  time.  One  bottle  feeding  a  day  makes  it 
much  easier  for  many  women  and  enables  them  to  nurse  their 
babies  when  they  would  otherwise  not  be  able  to  do  so.  An  addi- 
tional advantage  in  one  bottle  feeding  a  day  is  that  the  baby 
becomes  accustomed  to  the  bottle  and  weaning  is,  therefore,  much 
easier  when  it  becomes  necessary.  It  is  especially  pernicious  to 
nurse  the  baby  off  and  on  all  night.  If  this  is  done,  the  sleep  of 
both  mother  and  baby  is  disturbed  and  they  suffer,  the  mother  the 
more,  from  the  loss  of  sleep.  A  baby  should  not  be  nursed  more 
than  once  in  the  night,  and  this  nursing  should  be  stopped  when 
the  baby  is  a  few  weeks  old. 

Waking  to  Nurse. — It  is  claimed  by  some  authorities  that  a 
baby  should  not  be  waked  to  nurse,  but  should  be  allowed  to  sleep 
as  long  as  it  desires  and  nurse  when  it  awakens,  the  only  rule  as  to 
the  length  of  the  interval  between  nursings  being  that  it  shall  not 
be  less  than  2  hours,  so  as  to  avoid  feeding  before  the  stomach  is 
empty.  There  is  no  doubt  that  babies  will  thrive  on  this  system  of 
breast  feeding,  as  they  will  on  almost  any  scheme  of  breast  feeding. 
This  method  is,  however,  not  suited  to  the  exigencies  of  modern 
life.  Most  women  have  to  arrange  their  time  systematically  in 
order  to  fill  all  their  engagements  and  cannot  wait,  therefore,  on 
the  baby's  convenience.  It  is  much  wiser,  on  the  whole,  to  wake 
the  baby  at  the  proper  time.  A  normal  baby  that  is  fed  regularly 
wakes  in  most  instances  at  regular  intervals  and,  in  any  case,  will 
quickly  go  to  sleep  again  after  being  nursed. 

Alternate  Breasts. — If  the  supply  of  milk  is  sufficient,  it  is 
usually  advisable  to  give  the  breasts  alternately.  By  this  method 
*  Morse:  Amer.  Journal  of  Diseases  of  Children,  1912,  iv,  229. 


DURATION  OF  NURSING  139 

the  breasts  are  more  thoroughly  emptied  and  the  production  of 
milk  is  encouraged.  If  both  are  given  at  the  same  time,  they  are 
not  emptied  and  the  production  of  milk  is  discouraged.  There  is, 
moreover,  a  tendency  to  reversion  to  the  colostrum  stage.  If  the 
supply  of  milk  is  insufficient,  it  is  advisable  to  give  both  breasts  at 
each  feeding.  The  baby  in  this  way  gets  a  sufficient  amount  of 
food,  the  breasts  are  emptied  and  the  production  of  milk  is  en- 
couraged. 

Duration  of  Single  Nursing. — If  the  supply  of  milk  is  abundant 
and  the  baby  well  and  vigorous,  it  will  usually  occupy  about 
twenty  minutes  in  nursing.  Many  normal  babies  will,  however, 
take  only  ten  or  fifteen  minutes  in  nursing.  The  time  taken  in 
nursing  varies  according  to  the  sucking  strength  of  the  baby,  the 
amoimt  of  milk  in  the  breasts,  and  whether  the  breast  is  one  which 
it  is  hard  or  easy  to  empty.  It  must  be  remembered  in  this  connec- 
tion that  the  milk  flows  most  freely  at  the  beginning  of  a  nursing, 
and  that  the  amount  obtained  diminishes  progressively  with  the 
duration  of  the  nursing.  The  baby  gets  more  than  one-half  of  the 
meal  in  the  first  five  minutes,  more  than  one-quarter  in  the  next 
five  minutes,  and  but  comparatively  Uttle  after  this.^  If  the  baby 
nurses  more  than  thirty  minutes  there  is  something  wrong.  The 
trouble  may  be  that  the  supply  of  milk  is  insufficient,  or  that  the 
baby  is  too  feeble  to  nurse  vigorously  and  continuously.  The 
baby  should  not  drop  off  to  sleep  while  nursing.  If  it  does,  it 
means  that  the  supply  is  insufficient  and  he  gives  up  after  getting 
a  httle,  that  he  is  not  hungry  and  that  the  intervals  should  there- 
fore be  lengthened,  or  that  he  is  feeble  or  sick  in  some  way.  While 
the  supply  of  milk  is  greatest  at  the  beginning  of  the  nursing, 
the  strength  of  the  milk  increases  progressively  throughout  the 
nursing,  the  total  solids  being  greater  at  the  end  than  at  the  begin- 
ning of  a  nursing.  This  difference  is,  however,  not  great  enough 
to  be  of  much  practical  importance. 

Amoimt  Taken  at  Each  Nursing. — ^The  amount  taken  at  a  nurs- 
ing varies  materially  from  nursing  to  nursing  and  bears  no  relation 
to  the  theoretical  size  of  the  stomach.  A  baby  will  take  two 
ounces  at  one  feeding,  and  six  ounces  at  the  next,  and  so  on.  A 
baby  three  weeks  old  will  sometimes  take  as  much  as  six  ounces 
at  a  nursing,  and  one  of  two  months  as  much  as  eight  ounces  at  a 
nursing,  and  so  on.  The  amount  taken  in  twenty-four  hours  will, 
however,  be  approximately  the  same  from  day  to  day,  increasing, 
of  course,  with  the  age  of  the  baby.^    Variations  in  the  amount  of 

»  Feer:  Jahrbuch  f.  Kinderheilkunde,  1896,  xlii,  195. 
*  Peters:  Archiv.  f.  Kinderheilkunde,  1902,  xxxiii,  295. 


140  DIFFICULTY  IN  TECHNIQUE 

fat  in  the  milk  do,  however,  influence  the  total  amount  taken  in 
twenty-four  hours,  less  being  taken  when  the  percentage  of  fat 
is  high.  The  explanation  of  the  difference  in  the  amount  taken  at 
different  feedings  is  probably  either  that  there  is  a  variation  in  the 
supply  of  milk  or  that  the  baby  is  not  as  hungry  at  one  time  as  at 
another.  If  it  has  taken  a  large  amount  at  one  feeding,  it  will 
naturally  not  take  as  much  at  the  next  and  vice  versa.  The 
explanation  of  the  fact  that  a  baby  can  take  an  amount  at  a  single 
nursing  far  in  excess  of  its  gastric  capacity  is  that  the  milk  passes 
directly  into  the  duodenum,  even  during  the  act  of  nursing. 

Difficully  in  Technique  of  Nursing. — If  a  baby  does  not  nurse 
well,  the  trouble  may  be  with  the  baby  or  with  the  mother.  If  the 
trouble  is  with  the  baby,  it  may  be  some  deformity  of  the  lips  or 
mouth,  nasal  obstruction  from  adenoids  or  some  other  cause,  which 
interferes  with  nursing,  or  weakness.  Older  babies  that  have  been 
fed  on  the  bottle  are  often  unwilling  to  take  the  breast,  because 
they  are  unaccustomed  to  it.  Babies  that  are  partly  bottle  and 
partly  breast-fed  will  often  refuse  the  breast  because  they  have  to 
work  harder  to  get  the  milk  from  the  breast  than  they  do  to  get  it 
from  the  bottle. 

Retracted  or  small  nipples  are  the  most  common  cause  of 
difficulty  in  nursing  on  the  part  of  the  mother.  In  rare  instances 
the  nipples  are  too  large.  Cracked  nipples  also  frequently  interfere 
with  satisfactory  nursing.  Many  mothers  do  not  know  how  to 
hold  a  baby  to  make  it  comfortable  while  nursing.  Other  mothers, 
through  nervousness,  disturb  the  baby  and  prevent  it  from  taking 
hold  and  nursing  satisfactorily. 

Treatment. — Deformities  of  the  mouth  and  hps  must  be  cor- 
rected. In  general,  it  is  not  wise  to  operate  on  a  hare-lip  until  the 
baby  is  at  least  six  weeks  old,  or  on  a  cleft-palate  until  it  is  at  least 
six  months  old.  The  baby  can  be  fed  with  breast-milk  by  means  of 
a  dropper,  spoon,  Breck  feeder  or  tube  in  the  meantime.  Adenoids 
should  be  removed  at  once  if  they  cause  interference  with  nursing, 
no  matter  how  young  the  baby  may  be.  Feeble  babies  can  be  fed 
wholly  or  in  part  in  the  same  ways  as  those  with  deformities  of  the 
mouth  and  Ups,  Babies  that  are  unwilling  to  take  the  breast  can 
usually  be  starved  to  it.  Putting  sugar  on  the  nipples,  pressing 
some  of  the  milk  into  their  mouths  at  the  beginning  of  nursing,  or 
the  use  of  a  nipple-shield  will  sometimes  induce  them  to  take  hold. 
They  will  sometimes  nurse  in  the  dark  or  when  blindfolded,  when 
they  will  not  otherwise. 

Care  of  the  Nipples. — Something  can  be  done  during  pregnancy 
to  bring  out  retracted  nipples  by  manipulation,  careful  application 


CARE  OF  NIPPLES  141 

of  a  breast-pump  and  sucking.  The  nipples  should  be  carefully 
washed  and  cleaned  during  the  latter  days  of  pregnancy  in  order  to 
remove  the  excess  of  epithehum  and  to  clear  the  openings  of  the 
ducts. 

The  nipples  should  be  washed  before  and  after  each  nursing  with 
sterile  water  or  with  a  saturated  solution  of  boracic  acid  and 
thoroughly,  but  carefully,  dried  with  a  soft  cloth  or  absorbent 
cotton.  It  is  wise  to  protect  them  with  a  cloth  moistened  with 
albolene  or  boracic  acid  ointment  between  the  nursings.  If  the 
nipples  are  tender  they  may  be  washed  with  a  50%  solution  of 
alcohol.  If  the  nipples  become  cracked,  the  baby  should  not  be 
allowed  to  nurse,  except  through  a  nipple-shield.  If  it  does  not 
throughly  empty  the  breasts  in  this  way,  they  should  be  emptied 
by  massage  or  a  breast-pump.  Cleanliness  and  a  simple  ointment, 
like  boracic  acid  ointment,  are  usually  sufficient  to  heal  them. 
In  some  instances,  however,  it  is  necessary  to  touch  the  cracks 
with  a  1%  or  2%  solution  of  nitrate  of  silver.  If  the  breasts  are 
full  or  tender,  they  should  be  supported  with  a  breast-binder  and 
kept  empty  by  massage  and  a  breast-pump.  It  is  safer,  as  a  rule, 
to  take  the  baby  off  of  an  inflamed  breast  and  empty  the  breast 
by  massage  or  with  a  breasl-pump.  If  the  milk  contains  no  pus 
corpuscles  there  is  probably,  however,  no  risk  to  the  baby,  if  the 
nursing  is  continued. 

Breast-Pumps  and  Nipple-Shields. — ^The  so-called  English 
breast-pump  is  very  satisfactory.  Caldwell  ^  has  recently  de- 
scribed a  simple  and  effective  pump  which  the  mother  works  by 
her  own  suction  and  by  which  the  milk  is  collected  in  the  nursing 
bottle  in  which  it  is  to  be  given.  The  glass  nipple-shields  with  a 
rubber  nipple  are  the  best.  A  baby  will  often  nurse  better  from 
a  shield  if  it  is  first  filled  with  milk. 

Care  of  Baby's  Mouth. — There  is  always  danger  of  infection 
of  the  nipples  and  breasts  from  the  baby's  mouth,  if  it  is  not  kept 
clean.  The  condition  of  the  baby's  mouth  must,  therefore,  be 
watched.  It  is  far  more  likely  to  become  inflamed  and  infected,  if 
it  is  washed  than  if  it  is  left  alone.  The  baby's  mouth  should, 
therefore,  not  be  washed.  A  swallow  of  water  after  nursing  is  all 
that  is  necessary. 

Method  of  Nursing  Baby. — ^The  baby  should  be  held  lying  on 
its  side  with  its  head  a  little  elevated.  It  must  be  everywhere 
supported,  so  that  it  is  relaxed  and  comfortable.  The  breast  above 
the  nipple  must  be  pressed  away  from  its  nose,  so  that  it  can 
breathe  freely.  The  mother  and  attendants  must  be  quiet  and 
*  Caldwell:  Amer.  Journ.  Diseases  of  Children,  1915,  ix,  391. 


142  ABNORMAL  BREAST  MILK 

composed.    Otherwise  the  baby  is  disturbed  and  excited  and  will  | 

not  nurse  well.  Vomiting  after  nursing  can  sometimes  be  pre- 
vented by  having  the  mother  lie  down  beside  the  baby  while  she 
nurses  it.  In  other  instances  it  is  advisable  to  hold  the  baby  up- 
right every  few  minutes  during  the  nursing  in  order  that  it  may 
get  up  the  air  which  it  swallows  and  which  would  otherwise  cause 
vomiting. 

Not  all  Human  Milk  is  Good  Milk. — Everyone  agrees  that  hu- 
man milk  is  the  best  food  for  infants.  It  is  equally  true,  however, 
that  not  all  human  milk  is  good  milk.  Some  milks  will  not  agree 
with  any  baby.  Other  milks  will  agree  with  one  babj''  and  not  with 
another.  A  milk  which  suits  one  baby  will  not  suit  another,  and 
what  suits  the  second  baby  will  not  suit  the  first  baby.  It  is  im- 
possible to  determine  from  an  analysis  of  a  milk  whether  it  will  or 
will  not  agree  with  a  given  baby.  This  can  only  be  told  by  expe- 
rience. Babies  will  often  thrive  on  a  milk  which  would,  from  its 
analysis,  seem  most  unsuitable.  The  same  baby  will  often  thrive 
on  different  types  of  milk.  While  it  is  impossible  to  determine 
from  an  analysis  of  the  milk  whether  it  will  or  will  not  agree  with 
a  baby,  it  is,  however,  often  possible,  if  a  milk  is  not  agreeing  with 
a  baby,  to  tell  from  the  analysis  why  it  does  not.  If  a  milk  does 
not  agree  with  a  baby,  the  most  common  abnormality  in  the  milk 
is  an  excessive  amount  of  proteins.  The  next  most  common  abnor- 
mality is  an  excess  of  fat.    There  is  very  seldom  an  excess  of  sugar. ") 

Types  of  Abnormal  Milk. — Human  milk  may  be  unsuitably  orf  ■^Oi/*> 
abnormal  in  many  ways.    Three  general  types  can  be  recognized :)  ^'^*' ' 

(1)  All  elements  too  high. 

(2)  Fat  and  sugar  low,  proteins  high. 

(3)  Fat  and  sugar  very  low,  proteins,  very  high. 

The  first  type  is  most  often  found  in  indolent  women  of  the 
wealthy  classes,  who,  being  blessed  with  a  good  digestion,  eat  too 
much  and  too  rich  food.  An  example  of  such  milk  is  the  follow- 
ing: 

Fat 5.00% 

Sugar 7.50% 

Proteins 2.60% 

There  is  no  difficulty  in  correcting  this  type  of  milk,  provided 
the  woman  will  eat  properly  and  take  exercise.  It  is,  however, 
unfortunately  rather  hard  to  induce  such  women  to  change  their 
habits. 


ABNORMAL  BREAST  MILK  143 

The  second  type  is  most  often  found  in  women  of  the  poorer 
classes  who  are  compelled  to  work  hard  and  do  not  have  sufficient 
food.  It  is,  in  fact,  a  starvation  milk.  A  typical  analysis  of  such  a 
milk  is 

Fat 1.75% 

Sugar 4.50% 

Proteins 2.50% 

This  type  of  milk  is  also  easily  changed  by  giving  sufficient  food 
and  diminishing  the  work.  Unfortunately,  it  is,  in  this  instance 
also,  difficult  to  remedy  the  underlying  social  conditions. 

The  third  type  is  usually  found  in  the  highly-strung,  over-edu- 
cated and  highly-civiUzed  women  of  the  large  cities,  but  may  be 
found  in  neurotic  women  of  any  class  or  community.  A  charac- 
teristic analysis  of  this  type  of  milk  is 

Fat 1.00% 

Sugar 4.00%      . 

Proteins 3.75% 

It  is  practically  impossible  to  modify  this  type  of  milk,  because  it 
is  impossible  to  change  the  fundamental  abnormaUty  of  the  wo- 
man's nervous  make-up. 

Analysis  of  Breast-Milk. — Too  much  reliance  must  not  be 
placed  on  an  analysis  of  the  breast-milk,  because  the  composition 
of  milk  varies  in  the  same  woman  from  day  to  day  and  from  nurs- 
ing to  nursing.  It  also  differs  at  different  periods  of  the  same  nurs- 
ing. An  analysis  is  valueless,  therefore,  unless  all  the  milk  is  taken 
from  the  breast,  or  at  least  samples  from  the  beginning,  the  middle 
and  the  end  of  the  nursing.  The  results  of  a  single  examination, 
even  if  the  milk  is  properly  taken,  may  also  be  misleading,  because 
of  the  variation  from  day  to  day  and  nursing  to  nursing.  Positive 
conclusions  can  be  drawn  only  when  the  results  of  several  examina- 
tions are  similar. 

The  Normal  Breast-Fed  Infant.^ — ^A  baby  that  is  thriving  on 
the  breast  should  gain  from  six  to  eight  ounces  a  week  during  the 
first  five  months,  and  from  four  to  six  ounces  a  week  during  the 
rest  of  the  first  year.  Smaller  but  steady  gains  are,  however,  not 
necessarily  abnormal.  It  should  double  its  birth  weight  in  the 
first  five  months,  and  treble  it  at  the  end  of  the  first  year,  or  a 
Uttle  later.  It  should  have  from  two  to  four  smooth,  orange-yellow 
stools  of  the  consistency  of  thick  pea-soup  daily  during  the  first  few 
months,  and  from  one  to  three  similar  stools  of  somewhat  greater 


144  THE  ABNORMAL  BREAST-FED  INFANT 

consistency  during  the  rest  of  the  first  year.  It  should  not  vomit 
unless  it  is  disturbed  or  shaken  up  soon  after  a  feeding.  It  should 
not  cry  unless  hungry  or  when  uncomfortable  from  wet  diapers, 
wrinkles  in  its  clothing,  and  so  on.  Its  flesh  should  be  hard  and 
firm,  its  lips,  cheeks  and  nails  pink.  It  should  sleep  from  twenty  to 
twenty-two  hours  out  of  the  twenty-four  during  the  first  two 
months,  and  about  sixteen  hours  a  day  during  the  latter  half  of 
the  year.  It  should  be  happy  when  awake,  active  when  given  the 
opportunity. 

Theoretically  the  normal  baby  should  gain  regularly  every  day 
and  should  never  lose.  Practically  this  never  happens.  The  baby 
gains  one  day,  remains  stationary  another  day  and  loses  on  a  third, 
there  being,  however,  a  steady  gain  from  week  to  week.  Very 
few  babies,  however,  get  through  the  year  without,  for  some  reason, 
which  may  or  may  not  be  apparent,  failing  to  gain  or  losing  for  one 
or  more  weeks. 

Many  babies  that  are  gaining  regularly  and  apparently  thriving 
in  every  way  on  the  breast  have  abnormal  stools.  The  attempt 
should  be  made  to  correct  these  stools  by  modification  of  the  milk 
through  regulation  of  the  mother's  diet  and  life.  The  baby  should 
not  be  taken  off  the  breast,  however,  even  if  the  attempt  is  un- 
successful. A  baby  that  is  gaining  and  thriving  in  other  ways 
should  never  be  weaned  simply  because  the  stools  are  abnormal, 
no  matter  how  abnormal  they  may  be.  Many  a  baby  has  been  in- 
jured, and  not  a  few  killed,  by  being  taken  off  the  breast  on  this 
account.  It  must  never  be  forgotten  that  stools  which  in  the 
artificially-fed  baby  mean  serious  disturbance  of  the  digestion  and 
demand  prompt  modification  of  the  food  can  be  practically  dis- 
regarded in  the  breast-fed,  provided  the  babies  are  thriving  in 
other  respects. 

The  Abnormal  Breast-Fed  Infant. — When  a  breast-fed  baby, 
which  is  not  gaining  properly,  has  one  or  more  normal  stools  daily 
and  is  not  vomiting,  it  is  almost  certain  that  the  failure  to  gain  is 
not  due  to  any  defect  in  the  quantity  or  quality  of  the  milk.  The 
source  of  the  trouble  must  be  sought  elsewhere.  It  will  then  be 
found  that  the  baby  is  being  improperly  handled  in  some  way  or 
that  it  has  some  disease.  It  may  be  that  it  is  excited  too  much, 
that  it  does  not  get  enough  sleep,  that  it  does  not  get  enough  fresh 
air,  or  that  it  is  not  kept  warm  enough.  Hidden  tuberculosis, 
pyelitis  and  an  insufficient  supply  of  air  as  the  result  of  adenoids 
are  frequent  causes  of  failure  to  gain. 

Failure  to  gain  in  weight  may  or  may  not  be  associated  with 
symptoms  of  disturbance  of  the  digestion. 


THE  ABNORMAL  BREAST-FED  INFANT  145 

If  there  are  no  symptoms  of  disturbance  of  the  digestion  and 
the  baby  is  constipated,  as  it  usually  is,  the  food  is  deficient  in 
quantity,  quality,  or  both.  If  the  supply  of  food  is  sufficient  to 
allay  the  pangs  of  hunger,  the  baby  will  not  appear  hungry,  even 
if  the  food  is  entirely  inadequate  to  enable  it  to  gain  in  weight. 

The  only  way  to  determine  how  much  milk  a  baby  is  getting 
from  the  breast  is  to  weigh  it  before  and  after  each  nursing  for 
twenty-four  hours.  The  difference  in  weight  shows  the  amount  of 
milk  taken,  as  an  ounce  of  milk  weighs  practically  one  ounce  avoir- 
dupois. It  is  not  sufficient  to  weigh  the  baby  before  and  after  one 
or  two  nursings,  because  of  the  difference  in  the  amount  of  milk 
taken  at  different  nursings.  The  total  amount  taken  in  twenty- 
four  hours  must  always  be  determined.  It  is,  of  course,  unneces- 
sary to  undress  the  baby  in  order  to  weigh  it.  If  the  baby  is  restless 
and  it  is  hard  to  weigh  it  accurately,  the  same  result  can  be  ob- 
tained by  weighing  the  mother  before  and  after  nursing.  What  she 
loses  represents,  of  course,  the  amount  of  milk  taken  by  the  baby. 

Other  methods  of  estimating  the  amount  of  milk  are  very  unre- 
liable. It  is  impossible  to  tell  the  amount  of  milk  from  the  size  of 
the  breasts.  Many  large  breasts  secrete  but  little  milk,  while 
other  small  breasts  secrete  a  considerable  amount  of  milk.  It  is 
impossible,  also,  to  determine  the  amount  of  milk  by  attempting  to 
express  it  or  by  taking  it  out  with  a  breast-pump,  because  a  baby 
will  often  get  a  large  amount  of  milk  from  the  breast  when  but  lit- 
tle or  nothing  can  be  obtained  by  expression  or  with  a  pump.  Evi- 
dence of  considerable  importance  in  favor  of  an  insufficient  supply 
of  milk  is  when  a  baby  wakes  up  hungry  some  time  before  every 
feeding.  Other  suggestive  evidence  is  when  a  baby  drops  the 
nipple  during  the  feeding  and  cries  with  anger,  or  when  it  grabs  the 
nipple  and  shakes  it  as  a  puppy  does  a  root. 

The  quahty  of  the  milk  can  only  be  determined  by  chemical 
analysis.  Great  care  must  be  exercised,  however,  in  the  interpre- 
tation of  the  findings  of  such  an  analysis,  as  has  already  been  ex- 
plained. Under  these  conditions  the  milk  is  usually  weak  in  all  its 
constituents,  or  the  percentage  of  fat  is  very  low,  while  the  other 
elements  are  approximately  normal. 

When  there  are  symptoms  of  a  disturbance  of  the  digestion, 
there  is  either  an  excessive  amount  of  milk  or  the  quality  of  the 
milk  is  abnormal.  When  there  is  an  excessive  amount  of  milk  the 
baby  usually  vomits,  especially  soon  after  nursing,  and  has  too 
many  stools,  which,  in  most  instances,  are  in  some  way  abnormal. 
The  quantity  of  the  milk  can  only  be  positively  determined,  how- 
ever, by  weighing  the  baby  or  the  mother  before  and  after  each 


146  MODIFICATION  OF  BREAST  MILK 

nursing  for  at  least  twenty-four  hours.  Abnormalities  in  the  com- 
position of  the  milk  are  shown  by  colic,  vomiting  and  abnormal 
stools.  The  abnormality  is  usually  an  excess  of  fat  or  proteins, 
more  often  of  proteins,  rarely  of  sugar.  An  excess  of  fat  is  shown 
in  most  instances  by  the  presence  of  small,  soft  curds  in  the  stools, 
the  typical  soap  stool  being  unusual  in  the  breast-fed  baby.  When 
there  is  an  excess  of  proteins,  the  stools  are  likely  to  be  watery,  to  be 
somewhat  brownish  in  color  and  to  contain  mucus.  They  are  often 
greenish  and  frequently  contain  mucus  when  the  milk  is  abnormal 
in  any  way,  but  the  typical,  green,  fermented,  irritating  stool  of  an 
excessive  amount  of  sugar  is  seldom  seen.  The  only  way  in  which 
the  error  in  the  composition  of  the  milk  can  be  accurately  deter- 
mined, however,  is  by  chemical  analysis  of  the  milk,  due  regard 
being  paid  to  the  possibilities  of  mistakes  in  drawing  conclusions 
from  such  analyses. 

Modification  of  Breast-Milk. — The  secretion  of  breast-milk 
and  the  various  factors  which  influence  it  have  been  discussed  in  a 
previous  chapter.  It  will  perhaps  be  well,  nevertheless,  to  review 
the  subject  from  the  clinical  standpoint.  In  the  first  place,  lacta- 
tion is,  or  should  be,  a  physiological,  not  a  pathological  process. 
A  nursing  woman  is  in  a  normal,  not  an  abnormal,  condition. 
She  should,  therefore,  lead  the  same  sort  of  life  when  she  is  nursing 
that  she  does  when  she  is  not  nursing,  provided  her  manner  of 
hving  is  a  normal  one.  In  view  of  the  fact  that  there  is  a  certain 
amount  of  additional  strain  in  nursing,  she  should  be  careful  not  to 
overdo  or  to  get  overfatigued.  Her  diet  should  be  that  to  which 
she  is  accustomed  when  she  is  not  nursing.  There  is  no  reason  why 
she  should  not  eat  anything  which  does  not  disturb  her  digestion, 
but  should,  as  when  not  nursing,  avoid  articles  of  food  which  dis- 
agree with  her.  There  is  very  little  in  the  old  theory  that  a  nurs- 
ing woman  should  avoid  certain  fruits  and  vegetables  because  they 
will  disturb  the  baby's  digestion.  It  is  true  that  sometimes  when  a 
given  woman  eats  a  given  thing  the  baby  will  be  disturbed.  It  is 
impossible  to  tell  in  advance,  however,  what  this  thing  will  be. 
Moreover,  the  thing  which  causes  disturbance  in  one  instance  will 
not  cause  disturbance  in  the  next,  while  something  else  will.  A 
nursing  woman  should,  therefore,  eat  a  general  diet,  avoiding 
articles  of  food  which  disturb  her  digestion.  If  her  baby  is  upset, 
she  should  try  to  remember  what  unusual  article  of  food  she  has 
eaten.  If  the  baby  is  upset  when  she  eats  it  again,  she  should 
avoid  it  in  the  future. 

Modification  of  Quantity  of  Breast-Milk. — In  the  first  place, 
it  must  be  remembered  that  Nature  tends  to  accommodate  the 


MODIFICATION  OF  BREAST  MILK  147 

supply  of  breast-milk  to  the  demand.  If  but  little  is  taken,  little 
will  be  produced.  If  much  is  taken,  much  will  be  produced.  The 
best  stimulant  to  the  secretion  of  milk  is  the  thorough  emptying  of 
the  breast.  There  is  nothing  else  which  tends  to  increase  the 
quantity  so  much.  The  next  best  stimulants  to  the  secretion  of 
milk  are  a  liberal,  general  diet  and  a  normal  life.  Increasing  the 
quantity  of  liquid  in  the  diet  increases  the  quantity  of  milk  to  a 
certain  extent.  It  is  useless,  however,  for  a  woman  to  take  more 
than  a  quart  of  extra  liquid  daily.  More  than  this  either  disturbs 
her  digestion  or  makes  her  grow  fat.  This  extra  liquid  should 
not  be  too  rich.  It  is  given  chiefly  for  its  action  as  a  Uquid,  not  as  a 
food.  If  it  is  given  in  the  form  of  chocolate,  eggnogs,  and  things  of 
like  nature,  it  takes  away  the  appetite  for  solid  food,  and  the 
total  ingestion  of  food  is  not  only  not  increased  but  often  dimin- 
ished. Milk  and  cocoa  shells  are  probably  the  best  drinks.  Gruels 
seem  to  have  a  certain  action  as  galactagogues.  So  do  malt  liquors 
in  some  instances.  It  is  better  not  to  use  them  as  a  rule,  however, 
because  they  are  likely  to  disturb  the  digestion  and  fatten  the 
mother.  There  is  no  danger  to  the  baby  from  their  alcoholic  con- 
tent. There  are  no  drugs  which,  whether  taken  internally  or  applied 
externally,  can  increase  the  flow  of  milk  to  any  appreciable  extent. 

It  is  seldom  necessary  to  diminish  the  quantity  of  milk.  Diminu- 
tion in  the  amount  of  food  and  liquid  ingested  will  usually  speedily 
diminish  the  supply  of  milk.  Moreover,  if  the  breasts  are  not 
thoroughly  emptied.  Nature  will  quickly  reduce  the  supply. 
External  applications  are  usually  not  efficacious  and  always  in- 
advisable. The  bowels  may  be  opened  freely,  if  necessary,  to  re- 
duce the  amount  of  milk  temporarily. 

Modification  of  Quality  of  Breast-Milk. — ^When  the  total  soUds 
of  the  milk  are  all  high,  as  the  result  of  overeating  and  lack  of 
exercise,  they  can  be  reduced  by  regulation  of  the  diet  and  exercise. 
When  they  are  low,  as  the  result  of  starvation  and  malnutrition, 
they  can  be  increased  by  proper  food  and  care.  They  can  also  be 
influenced  to  a  certain  extent  by  varying  the  intervals  between 
nursings.  Lengthening  the  intervals  diminishes  the  total  solids; 
shortening  the  intervals  increases  them. 

It  has  been  taught  for  many  years  that  the  amount  of  fat  in 
the  milk  varies  directly  with  the  amount  of  protein  in  the  food. 
This  teaching  is,  however,  erroneous,  the  only  way  in  which  the 
protein  in  the  food  can  increase  the  fat  in  the  milk  being  by  im- 
proving the  general  condition.  The  amount  of  fat  in  the  food  has 
but  httle  influence  on  the  amount  of  fat  in  the  milk.  If  the  mother 
is  underfed,  an  increase  in  the  fat  in  the  food  will  temporarily  re- 


148  MODIFICATION  OP^  BREAST  MILK 

suit  in  an  increase  in  the  fat  in  the  milk.  If  she  is  not  underfed,  an 
increase  in  the  fat  in  the  food  does  not  increase  the  fat  in  the  milk. 
An  excessive  amount  of  fat  in  the  milk  is  most  often  due  to  an 
excessive  amount  of  food  in  general  rather  than  to  an  excess  of 
any  one  element  and  can  be  diminished  best  by  cutting  down  the 
food  as  a  whole.  An  insufficient  amount  of  fat  in  the  milk  is 
usually  due  to  malnutrition.  It  can  be  increased  by  building  up 
the  general  condition  by  increasing  the  supply  of  food  and  regula- 
tion of  the  life.  An  increase  in  the  amount  of  fat  in  the  food  will 
also  sometimes  temporarily  cause  an  increase  in  the  percentage 
of  fat  in  the  milk.  When  a  breast-milk  is  low  in  fat,  but  other- 
wise of  good  quality,  it  is  easy  to  make  up  for  the  deficiency  of 
fat  by  giving  the  baby  cream  with  the  nursings.  Enough  cream 
should  be  given  to  bring  the  percentage  of  fat  to  the  proper  level. 
For  example,  if  a  baby  is  taking  four  ounces  of  breast-milk,  con- 
taining 1%  of  fat,  the  addition  of  one-half  ounce  of  gravity  cream 
will  raise  the  percentage  of  fat  to  three.  The  cream  may  be  given 
before  or  after  the  nursing,  but  is  best  given  in  the  middle  of  the 
nursing.  A  very  good  way  to  give  it  is  from  a  dropper  introduced 
into  the  mouth  beside  the  nipple  while  the  baby  is  nursing. 

The  percentage  of  the  sugar  in  the  milk  cannot  be  directly 
influenced  in  any  way.  It  tends  to  vary  directly  with  the  general 
condition  of  the  mother. 

The  percentage  of  protein  in  the  milk  can  be  influenced  to  a 
certain  extent,  according  to  Hoobler,  by  changes  in  the  diet. 
The  amount  of  protein  in  the  milk  can  be  increased  by  increasing 
the  proportion  of  protein  in  the  food  in  relation  to  that  of  the 
combined  fat  and  carbohydrate  and  by  increasing  the  proportion 
of  animal  to  vegetable  protein.  It  can  be  diminished  by  giving 
a  diet  containing  a  relatively  large  amount  of  fat  and  carbohy- 
drate in  proportion  to  the  protein  and  by  giving  most  of  the  pro- 
tein in  the  form  of  vegetable  protein.  The  protein  of  milk  is  the 
most  efficient  form  of  protein  for  the  production  of  protein  in 
human  milk.  The  most  common  cause  of  an  excessive  amount  of 
protein  is  nervousness.  If  the  mother's  nervous  condition  can  be 
quieted,  the  percentage  of  protein  will  diminish.  The  amount 
of  protein  can  also  be  diminished  by  exercise,  but  if  the  exercise 
is  excessive  and  causes  fatigue,  the  protein  will  be  increased.  In 
many  cases,  therefore,  when  the  woman  is  overtired,  the  protein 
can  be  diminished  by  rest. 

Mixed  Feeding. — ^When  a  woman  does  not  have  suflBcient  milk 
to  satisfy  her  baby,  the  baby  should  not  be  weaned,  but  should 
be  given  an  artificial  food  in  addition  to  the  breast-miUc.    If  the 


MIXED  FEEDING  149 

supply  of  milk  is  almost  sufficient,  the  baby  may  be  given  the 
artificial  food  entirely  at  one  or  at  two  feedings  and  the  breast  at 
the  others.  It  is  hardly  ever  advisable  to  omit  more  than  two 
nursings,  because  the  supply  of  milk  is  likely  to  diminish  still 
further  from  lack  of  stimulation  of  the  breasts,  if  more  than  this 
number  of  feedings  are  omitted.  If  there  is  much  deficiency  in 
the  supply,  the  breast  should  be  given  at  each  feeding,  followed 
by  an  artificial  food.  The  amount  of  artificial  food  to  be  given 
depends,  of  course,  on  the  amount  of  breast-milk.  This  is  best 
determined  by  weighing  the  baby  or  mother  before  and  after  nurs- 
ing and  giving  enough  artificial  food  to  make  up  the  proper  amount 
for  a  feeding.  It  is  usually  not  necessary  to  weigh  the  baby  be- 
fore and  after  every  feeding,  once  the  average  amount  obtaiaed 
from  the  breast  has  been  ascertained. 

No  attempt  should  be  made,  in  deciding  on  the  composition  of 
the  artificial  food,  to  imitate  the  composition  of  the  breast-milk. 
The  fact  that  the  baby  can  digest  human  milk  of  a  given  composi- 
tion does  not  indicate  at  all  that  it  can  digest  a  cow's  milk  mixture 
of  the  same  composition,  because,  although  the  percentages  of  the 
components  of  the  two  foods  may  be  the  same,  the  foods  are 
different.  One  is  human  milk;  the  other  is  cow's  milk,  in  spite  of 
the  fact  that  it  is  modified.  The  composition  of  the  artificial  food 
should  be  decided  on  general  principles,  based  on  the  age  and 
apparent  digestive  capacity  of  the  infant.  An  analysis  of  the 
breast-milk  is,  however,  sometimes  of  assistance  in  determining 
what  shall  be  the  composition  of  the  artificial  food,  because  in  some 
instances,  in  which  there  is  a  deficiency  of  some  element  in  the 
breast-milk,  it  can  be  corrected  by  an  increase  in  the  amoimt  of 
this  element  ia  the  artificial  food. 

Weaning. — ^A  baby  should  not  be  taken  off  the  breast  unless 
there  is  a  good  reason  for  doing  so.  A  baby  should  not  be  weaned 
during  the  early  weeks  of  life,  on  the  ground  that  the  milk  is 
unsuitable,  simply  because  the  baby  has  the  colic  and  abnormal 
stools.  It  is  wiser  to  wait  until  the  mother  is  out  of  bed  and  has 
resumed  her  usual  mode  of  Ufe  before  deciding  that  the  milk  will 
not  agree,  because  in  many  instances  the  symptoms  of  indigestion 
cease  and  the  baby  begins  to  thrive  as  soon  as  the  mother  gets  back 
to  her  normal  routine.  It  is  important,  on  the  other  hand,  not  to 
wait  too  long  and  allow  the  digestion  to  get  throughly  upset  be- 
fore weaning.  A  baby  should  not  be  weaned  hastily  on  account 
of  cracked  nipples.  These  can  almost  always  be  cured  and  the 
nursing  continued. 

A  baby  should  not  be  weaned  because  of  the  appearance  of 


150  WEANING 

menstruation.  As  a  matter  of  fact,  more  women  menstruate  dur- 
ing the  period  of  lactation  than  do  not.  Moreover,  the  changes 
which  take  place  in  the  chemical  composition  of  the  milk  during 
menstruation  are  no  greater  than  the  variations  which  are  likely 
to  occur  at  any  time  during  lactation.  In  most  cases  the  baby 
shows  no  evidences  of  disturbance  of  digestion  during  the  men- 
struation; in  some,  the  baby  ceases  to  gain  during  this  time  and 
has  the  colic  or  undigested  stools.  A  very  few  are  seriously  dis- 
turbed. They  should  not  be  weaned,  however,  but  should  be 
given  an  artificial  food  while  the  menstruation  lasts  and  put  back 
on  the  breast  as  soon  as  it  is  over. 

Pregnancy  is  an  indication  for  weaning.  It  is  impossible  for  a 
woman  to  nourish  three  individuals,  herself,  a  baby  on  the  breast 
and  another  in  utero.  Someone  is  sure  to  suffer,  most  often  the 
baby  on  the  breast. 

Acute  disease  in  the  mother  is  often  an  indication  for  weaning. 
If  the  disease  is  contagious,  it  is  usually  advisable  to  wean  the 
baby  to  protect  it  from  contagion.  The  younger  the  baby,  the 
less  likely  it  is,  however,  to  contract  the  disease,  because  babies 
are  born  with  a  natural  immunity  to  many  of  the  contagious  dis- 
eases. If  it  is  not  contagious,  the  question  of  nursing  must  be 
decided  on  the  circuriistances  in  the  individual  case.  If  the  dis- 
ease is  a  mild  one,  the  baby  may  be  kept  on  the  breast  or  taken 
off  temporarily  while  the  secretion  of  the  breast  is  kept  up  in  other 
ways.  If  the  disease  is  a  severe  one,  the  milk  will  probably  dry 
up  wholly  or  in  part  and  become  poor  in  quahty,  so  that  the  baby 
will  have  to  be  taken  off  the  breast  anyway,  even  if  the  condition 
of  the  mother  warranted  the  continuance  of  the  nursing,  which  it 
usually  does  not. 

The  development  of  a  chronic  disease  in  the  mother  is  usually  an 
indication  for  weaning.  In  other  instances,  although  the  baby  is 
thriving,  the  strain  of  nursing  enfeebles  and  debiUtates  the  mother. 
The  decision  as  to  weaning  in  such  cases  must  be  made  on  the 
merits  of  the  individual  case,  bearing  in  mind  the  fact  that  it  is  a 
mother's  duty  to  nurse  her  baby  as  long  as  she  can  do  it  without 
serious  detriment  to  herself.  The  older  a  baby  is,  the  less  depend- 
ent it  is  upon  breast-milk.  Weaning  is  justifiable,  therefore,  for 
slighter  disturbances  of  the  mother's  health  after  the  first  few 
months  than  it  would  be  before. 

It  is,  unfortunately,  not  often  necessary  to  decide  when  to  wean, 
because  the  milk  gives  out  and  the  baby  has  to  be  fed  artificially. 
Under  these  circumstances  the  milk  usually  diminishes  slowly  and 
the  baby  is  gradually  weaned  without  difficulty. 


WEANING  .  151 

If  the  supply  of  milk  continues  sufficient  in  amount,  it  is  ad- 
visable to  wean  the  baby  when  it  is  between  ten  and  twelve  months 
old.  Babies  rarely  thrive  on  the  breast  alone  more  than  a  year,  and 
seldom  as  long  as  this.  They  become  anaemic  and,  while  fat, 
usually  get  flabby.  The  cause  of  the  anaemia  is  that  breast-milk 
does  not  contain  sufficient  iron  to  cover  the  need  for  this  substance 
and  the  iron  stored  in  the  liver  at  birth  is  usually  used  up  before 
this  time.  If  a  baby  is  doing  fairly  well  on  the  breast,  it  is  in  most 
instances  advisable  to  continue  nursing  through  the  summer 
months,  even  if  the  baby  is  a  year  or  more  old  in  the  autumn,  be- 
cause babies  on  the  breast  are  much  less  liable  to  disturbances  and 
infections  of  the  digestive  tract  than  those  that  are  artificially  fed. 
A  baby  should  never  be  weaned  in  the  spring  to  avoid  weaning  in 
the  summer.  The  old  idea  that  it  is  very  dangerous  to  wean  babies 
in  the  summer  originated  in  the  fact  that  babies  weaned  in  the 
summer  got  contaminated  milk  and  were  therefore  made  sick, 
while  those  weaned  in  the  spring  got  uncontaminated  milk  and 
were  therefore  less  often  upset.  The  truth  of  the  matter  is  that  the 
older  a  baby  is,  the  better  able  it  is  to  take  an  artificial  food,  pro- 
vided that  food  is  suitable  and  clean. 

Babies  should  always  be  weaned  slowly,  if  possible.  It  is  much 
easier  for  the  mother  and  the  baby  is  much  less  likely  to  be  made 
ill  by  the  change  to  artificial  food.  If  it  is  made  ill,  it  can  usually 
be  put  back  on  the  breast  again  without  difficulty.  If  it  is  weaned 
suddenly  and  the  milk  is  gone,  as  it  usually  is  in  a  few  days,  the 
baby  cannot  get  anything  from  the  breast  at  first,  although  it  may 
later.  It  is  often  possible  to  bring  back  the  milk,  by  putting  the 
baby  to  the  breast  regularly,  even  several  weeks  after  breast  feed- 
ing has  been  omitted.  Weaning  is  much  easier  if  the  baby  has  been 
in  the  habit  of  taking  one  bottle  a  day  from  the  beginning  of  nursing. 
This  custom  is  advantageous  for  many  reasons.  It  gives  the  mother 
far  more  freedom,  enables  her  to  nurse  longer,  gets  the  baby 
accustomed  to  taking  the  bottle  as  well  as  the  breast  and  habit- 
uates it  to  the  digestion  of  an  artificial  food,  as  well  as  showing 
what  sort  of  artificial  food  it  can  take.  If  the  baby  has  had  one  or 
more  bottle  feedings  daily,  there  is  usually  no  trouble  in  weaning  it 
gradually  and  neither  mother  nor  child  is  disturbed.  If  it  is  more 
than  a  few  months  old  and  not  accustomed  to  the  bottle,  it  is 
much  harder  to  wean  it  gradually,  because  the  baby  wiU  refuse  all 
food  except  the  breast-milk  and  cannot  be  starved  into  taking  it. 
When  the  baby  will  not  take  food  in  any  way  except  from  the 
breast,  and  when  it  has  to  be  weaned  because  of  the  mother's 
illness  or  for  some  other  emergency,  the  breast  feeding  has  to  be 


152  WEANING 

stopped  suddenly.  It  is  best  to  separate  the  baby  from  its  mother, 
but  in  any  case  some  other  person  must  give  it  its  food.  It  cannot 
be  expected  to  take  it  from  its  mother,  whom  it  has  been  in  the 
habit  of  nursing.  A  httle  baby  should  be  given  the  bottle.  An 
older  baby  should  be  fed  from  a  glass  or  with  a  spoon.  If  it  refuses 
to  take  food  after  reasonable  coaxing  and  urging,  it  should  be 
allowed  to  go  hungry  until  the  next  feeding.  Most  babies  will 
yield  to  the  pangs  of  hunger  after  from  twenty-four  to  forty-eight 
hours  and  take  what  is  offered  to  them.  Occasionally,  however,  a 
baby  will  not  give  in  and  it  has  to  be  forced  to  take  food  or  fed  with 
a  tube  to  save  it  from  starvation.  Such  babies  should  always  be 
closely  supervised  because  of  the  possibiUty  of  the  development  of 
acidosis. 

When  a  baby  has  been  taking  one  feeding  of  artificial  food  a  day, 
there  is  no  difficulty  in  deciding  what  food  to  give  it.  The  same 
food  is  continued,  the  number  of  feedings  being  merely  increased. 
When  a  baby  that  has  been  exclusively  breast-fed  can  be  weaned 
slowly,  it  is  safe  to  give  it  a  fairly  strong  food.  It  is  usually  possible 
when  it  is  nine  months  or  more  old,  to  wean  it  directly  on  to  a 
dilution  of  whole  milk.  It  is  also  usually  advisable  to  add  starch  to 
the  mixture,  because  a  baby  of  this  age  is  perfectly  capable  of 
digesting  starch  and  because,  outside  of  milk,  starchy  foods  will 
form  the  principal  part  of  its  diet  for  the  next  few  months.  A 
mixture  of  three  parts  of  whole  milk  and  one  part  of  a  3%  barley 
water,  giving  fat  3%,  sugar  3.36%,  proteins  2.62%  and  starch 
0.75%,  is  a  reasonable  one  for  a  baby  of  this  age.  When  a  baby  is 
weaned  suddenly,  it  should  always  be  given  a  weaker  mixture  than 
a  baby  of  the  given  age  would  naturally  take,  in  order  to  avoid,  if 
possible,  disturbance  of  the  digestion  from  the  artificial  food.  It  is 
easy  to  strengthen  the  food  if  it  agrees,  difl&cult  to  correct  dis- 
turbances of  the  digestion  caused  by  too  strong  a  food.  The 
strength  of  the  mixture  must  depend,  largely,  of  course,  on  the 
age  of  the  baby.  Whey  mixtures  are  the  most  suitable  for  young 
babies,  mixtures  with  cereal  diluents  for  older  babies. 


CHAPTER  Xn 
WET-NURSES 

There  can  be  no  question  that  the  most  suitable  food  for  an 
infant  that  is  so  unfortunate  as  not  to  be  nursed  by  its  mother  is 
the  milk  of  another  woman.  In  fact,  the  milk  of  some  other  woman 
is  not  infrequently  better  for  a  baby  than  that  of  its  own  mother, 
when  she  is  nervous  and  feeble  while  the  stranger  is  placid  and 
strong.  In  former  days  so  little  was  known  about  the  artificial 
feeding  of  infants  that  unless  a  wet-nurse  was  obtained  the  pros- 
pects of  survival  of  a  baby  deprived  of  its  mother's  milk  were  not 
over-bright.  At  present,  however,  on  account  of  the  great  ad- 
vances which  have  been  made  in  artificial  feeding,  a  normal  baby 
can  be  expected  to  do  well,  if  artificially  fed,  provided  that  its 
feeding  is  directed  by  someone  familiar  with  the  subject.  Wet- 
nurses  are  not,  therefore,  the  necessity  for  well  babies  which  they 
were  in  the  past.  The  situation  is  different,  however,  in  the  case  of 
premature,  feeble  and  ill  babies.  Many  of  these  can  be  saved  by 
human  milk  who,  without  it,  would  surely  die.  Many  others,  who 
eventually  pull  through  on  artificial  feeding  after  months  of  illness, 
can  be  immediately  restored  to  health  by  human  milk.  A  very 
good  rule  to  follow  is  not  only  never  to  allow  a  baby  to  die,  but 
never  to  allow  a  baby  to  get  into  a  condition  in  which  it  may  die  of 
disturbances  of  nutrition  or  of  diseases  of  the  digestive  tract  with- 
out getting  it  a  wet-nurse,  provided  a  wet-nurse  can  be  procured. 

Wet-nurses  are  often  not  an  unmixed  blessing  in  a  family.  They 
realize  their  own  importance  and  not  infrequently  take  advantage 
of  it,  causing  much  disturbance  in  the  household.  In  general, 
however,  they  are  much  like  other  people,  good,  bad  and  indiffer- 
ent. Like  other  people,  too,  how  they  conduct  themselves  depends 
very  largely  on  how  they  are  treated.  Even  if  they  do  cause 
trouble,  however,  a  family  should  be  willing  to  put  up  with  con- 
siderable domestic  disquiet  for  the  sake  of  saving  their  baby's 
life.  Household  worries  are  not  to  be  compared  with  the  anxiety 
attendant  on  the  illness  of  a  baby. 

Every  mother  dislikes  to  have  another  woman  nurse  her  baby. 
She  should,  however,  in  the  first  place,  appreciate  the  fact  that  if 
she  was  fulfilling  her  duty  to  her  baby,  a  wet-nurse  would  not  be 

153 


154  WET-NURSES 

necessary,  and  in  the  second  place,  should  be  not  only  willing,  but 
glad,  to  sacrifice  her  own  feelings  for  the  good  of  her  infant.  There 
is,  of  course,  no  possibility  of  the  transference  of  mental,  moral  or 
physical  characteristics  from  the  nurse  to  the  baby.  If  there  was, 
it  would  be  far  better  for  many  babies  to  have  wet-nurses  than  to 
nurse  their  own  mothers.  It  makes  no  difference  to  the  baby  what 
is  the  color,  race,  creed,  disposition  or  moral  character  of  the  nurse, 
provided  her  milk  is  of  good  quality  and  sufficient  in  quantity. 

It  is  sometimes  said  that  it  is  wrong  to  employ  wet-nurses, 
because  it  is  immoral  to  deprive  one  baby  of  its  natural  nourish- 
ment and  give  it  to  another.  This  objection  is  not  well-founded, 
because  women  do  not  go  out  as  wet-nurses  for  pleasure,  but 
because  they  are  compelled  to  support  themselves  and  their  babies. 
The  wages  which  they  earn  as  wet-nurses  are  higher  than  they  can 
get  in  any  other  way  and,  if  they  board  their  babies  out,  they  are 
enabled  to  board  them  in  better  places  and  to  save  money  for  the 
future.  It  is  always  advisable,  however,  for  a  nurse  to  have  her 
own  baby  with  her.  Her  baby  can  then  be  properly  cared  for,  she 
becomes  fond  of  it  and  is  more  likely  to  care  for  it  in  the  future, 
and,  if  she  has  made  a  mistake,  is  more  likely  to  live  straight  in  the 
future  for  the  sake  of  her  baby.  It  is  often  an  advantage  to  the 
foster  baby  for  the  nurse  to  have  her  own  baby  with  her,  because 
she  is  happier  and  more  contented.  In  many  instances,  moreover, 
the  foster  baby  is,  at  any  rate  at  first,  not  strong  enough  to  empty 
the  breasts  and  to  keep  up  the  supply  of  milk.  Under  these  cir- 
cumstances, the  nurse's  baby  can  empty  the  breasts  and  keep  them 
going.    Many  women  are  able,  moreover,  to  nurse  both  babies. 

Wet-nurses  are  often  objected  to  on  the  ground  of  expense.  This 
must  vary,  of  course,  with  the  locality  and  the  circumstances  in  the 
individual  case.  It  is  safe  to  say,  however,  that  the  cost  of  the  wet- 
nurse,  including  her  board  and  that  of  her  baby,  will  be  less  than 
that  of  an  artificial  food  and  the  doctor's  bills,  which  will  be  saved. 

Qualifications  of  a  Wet-Nurse. — ^A  wet-nurse  should  be  healthy 
and  free  from  syphilis,  tuberculosis  and  other  chronic  diseases. 
No  woman  should  be  accepted  as  a  wet-nurse  without  a  complete 
physical  examination  by  a  competent  physician.  Syphilis  cannot 
be  positively  excluded,  even  if  neither  mother  nor  child  show  any 
evidences  of  it.  A  Wasserman  test  should  be  done,  therefore,  if  it 
is  practicable.  Equal  care  should  be  taken  to  determine,  however, 
that  the  baby  that  she  is  to  nurse  is  not  syphilitic.  It  is  just  as  bad 
to  have  the  baby  infect  the  wet-nurse  with  syphilis  as  it  is  to  have 
the  wet-nurse  infect  the  baby.  It  is  impossible  to  determine  from 
the  general  appearance  of  a  woman  or  from  the  size,  shape  or  feel- 


WET-NURSES  155 

ing  of  her  breasts  whether  she  has  or  has  not  a  good  supply  of  milk. 
Many  small,  thin  women  have  much  milk,  and  many  large, 
vigorous-looking  women  but  little  milk.  Small  breasts  often 
secrete  much  milk,  and  large  breasts  but  little  milk.  The  milk  is 
secreted  by  gland  tissue,  not  by  fat,  and  it  is  impossible  to  tell  by 
the  appearance  or  feeling  of  a  breast  what  is  fat  and  what  is  gland 
tissue.  The  ease  with  which  milk  can  be  expressed  from  the  breast 
is  also  unreliable  as  a  guide,  because  a  baby  can  often  obtain  much 
milk  from  a  breast  from  which  but  little  milk  can  be  expressed, 
while  in  other  instances  where  there  is  but  little  milk,  it  can  all  be 
easily  expressed.  The  only  way  in  which  the  quantity  of  milk 
which  the  breast  is  secreting  can  be  positively  determined  is  by 
weighing  the  wet-nurse's  own  baby  before  and  after  each  nursing 
for  at  least  twenty-four  hours.  Next  to  this  is  the  appearance  of 
her  baby.  If  it  is  thriving,  it  is  evident  that  it  gets  a  sufficient 
supply  of  milk  and  that  this  milk  is  of  good  quality.  It  is  useless 
to  examine  the  milk  to  determine  whether  it  will  be  suitable  for 
another  baby  or  not,  partly  because  of  the  variation  in  the  milk 
from  day  to  day  and  nursing  to  nursing,  and  partly  because  it  is 
impossible  to  know  in  advance  whether  or  not  a  given  milk  will 
agree  with  a  given  baby. 

The  composition  of  breast-milk  being  the  same  from  the  end  of 
the  colostrum  stage  until  nearly  the  end  of  lactation,  it  is  not 
necessary  that  the  foster  baby  and  the  nurse's  baby  shall  be  of  the 
same  age.  It  is  not  advisable,  however,  if  prolonged  nursing  is 
anticipated,  to  take  a  woman  as  a  wet-nurse  who  is  approaching 
the  end  of  the  period  of  lactation.  The  only  objection,  however, 
is  that  her  milk  is  likely  to  give  out  and  that  it  will  be  necessary  to 
procure  another  nurse.  It  must  be  remembered  that  if  a  feeble  or  a 
young  baby  is  put  to  the  breast  of  a  woman  with  an  abundance  of 
milk,  it  cannot  empty  the  breast  and  that,  the  stimulation  to 
secretion  being  removed,  the  supply  of  milk  will  diminish  and 
perhaps  cease.  Many  a  good  nurse  has  been  spoiled  in  this  way 
and  discharged  as  having  no  milk  when  the  trouble  was  not  with 
her  but  with  the  baby.  It  is  a  great  advantage  under  these  condi- 
tions for  the  nurse  to  have  her  own  baby  with  her  to  empty  the 
breasts.  A  small  or  young  baby  may  be  upset,  also,  by  taking 
too  much  food  from  a  full  breast  which  has  been  nursed  by  an 
older  child.  This  mishap  can  be  prevented  by  weighing  the  baby 
before  and  after  nursing. 

Management  of  Wet-Nurses. — A  wet  nurse  should  be  given  the 
sort  of  food  to  which  she  is  accustomed,  and  should  be  given  the 
sort  of  work  to  do  which  she  has  been  in  the  habit  of  doing.    If  a 


156  WET-NURSES 

woman  that  has  been  in  the  habit  of  doing  hard,  manual  labor  and 
eating  plain,  coarse  food  is  given  rich  food  and  allowed  to  sit  about, 
she  is  likely  to  become  ill  and  the  equilibrium  of  her  milk  is  almost 
certain  to  be  disturbed.  On  the  other  hand,  a  woman  that  has 
been  in  the  habit  of  leading  a  sedentary  life,  as  a  seamstress,  for 
example,  and  eating  dehcate  food,  cannot  do  hard  work  and  eat 
coarse  food  without  some  disturbance  of  her  milk  resulting.  Many 
a  good  wet-nurse  has  been  spoiled  by  lack  of  attention  to  these 
details. 

Methods  of  Procuring  Wet-Nurses. — It  is  almost  always  pos- 
sible to  find  a  wet-nurse  if  the  quest  is  undertaken  with  suflBcient 
energy.  They  are  most  readily  obtained  at  maternity  homes  and 
hospitals.  In  other  instances  they  may  be  obtained  through 
physicians  and  district  nurses,  or  by  advertising  for  them.  There 
has  been  in  Boston,  for  several  years,  a  Directory  for  Wet-Nurses, 
where  a  considerable  proportion  of  the  women  who  wish  to  be 
nurses  go.  They  are  examined  physically  and  the  Wasserman  test 
is  done  on  them.  The  quantity  and  quality  of  their  milk  are  also 
determined.  They  are  not  sent  out  unless  they  are  healthy  and 
their  milk  satisfactory.  When  they  are  through  with  one  case  they 
return  to  the  Directory  and  wait  for  another.  A  reasonable  fee  is 
charged  by  the  Directory  for  providing  them.^  This  is  the  best 
solution  of  the  problem  in  that  it  makes  it  easy  to  find  a  wet-nurse, 
assures  the  health  of  the  wet-nurse,  and  is  available  for  people  Hv- 
ing  not  only  in  the  vinicity  but  also  at  a  distance. 

In  many  instances  in  which  it  is  impossible  for  some  reason  to 
get  a  wet-nurse,  breast-milk  can  be  expressed  from  the  breasts  of 
one  or  several  women  and  fed  to  the  baby  in  a  bottle.  It  makes  no 
difference  in  the  result  whether  the  baby  gets  it  directly  from  the 
breast  or  indirectly  from  the  bottle.  It  is  breast-milk  just  the 
same.  The  Boston  Floating  Hospital  has,  for  several  seasons, 
obtained  considerable  amounts  of  breast-milk  in  this  way  through 
the  cooperation  of  several  of  the  philanthropic  and  nurses'  soci- 
eties in  Boston,  and  used  it  with  good  result.^ 

Breast-milk  may  also  be  preserved  by  freezing  and  used  when 
desired.  Schlossmann  always  has  a  number  of  wet-nurses  at  his 
hospital  and  during  the  winter  months,  when  he  does  not  use  so 
much  breast-milk  as  at  other  times,  he  saves  the  excess  and  freezes 
it,  holding  it  in  a  refrigerator  until  the  summer  months,  at  which 
time  the  demand  is  greater.  He  then  takes  it  as  needed  and 
claims  very  good  results  with  it. 

1  Talbot:  Journal  A.  M.  A.,  1911,  vol.  Ivi,  p.  1715. 

'^  Talbot:  Boston  Medical  and  Surgical  Journal,  1911,  cbdv,  290. 


SECTION   III 
ARTIFICIAL  FEEDING 

CHAPTER  Xni 
COW'S  MILK.    CHEMISTRY  AND  BIOLOGY 

COLOSTRUM 

The  colostrum  of  cow's  ftiilk  is  never  used  in  infant  feeding, 
except  by  accident,  and,  for  that  reason,  will  only  be  treated  in 
brief.  It  is  probable  that  the  explanation  of  the  presence  of  the 
colostrum  bodies  in  cow's  milk  is  the  same  as  in  human  milk. 

Colostrum  is  a  thick,  shiny,  yellowish  or  reddish  fluid  with  a 
taste  more  salty  than  that  of  normal  milk.^  It  is  sometimes  alka- 
line, but  more  often  acid.  The  specific  gravity  ranges  between 
1.046  and  1.080,  and  it  is  richer  in  soUds  than  ordinary  milk.  The 
appearance  and  composition  gradually  change  during  the  course 
of  a  week,  at  the  end  of  which  it  becomes  milk  suitable  for  use. 

The  following  analysis  given  by  EngUng  ^  shows  the  way  in  which 
the  milk  changes : 

TABLE  29 


Number  of  hours  after  calving 

Normal 
MUk 

Imme- 
diately 

10 

24 

48 

72 

Water 

73.17 

78.77 

80.63 

85.81 

86.64 

87.75 

Casein 

2.65 

4.28 

4.50 

3.25 

3.33 

3.00 

Albumin 
Globulin 

16.56 

9.32 

6.25 

2.31 

1.03 

0.50 

Extractives.  .  . 

3.54 

4.66 

4.75 

4.21 

4.08 

3.40 

Sugar 

3.00 

1.42 

2.85 

3.46 

4.10 

4.60 

Ash 

1.18 

1.55 

1.02 

0.96 

0.82 

0.75 

^  Jensen's  Milk  Hygiene  (Pearson) :  Phil,  and  London,  1907,  p.  12. 

'  Taken  from  Jensen's  Milk  Hygiene  (Pearson),  Phil,  and  London,  1907,  p.  30. 

157 


158       COW'S  MILK.   CHEMISTRY  AND  BIOLOGY 

The  fat  in  colostrum  has  a  somewhat  higher  melting  point  and  is 
poorer  in  volatile  fatty  acids  than  the  fat  in  ordinary  milk.'^ 

The  proteins  in  the  colostrum  of  cows  resemble  those  in  human 
milk  in  that  the  greater  part  of  them  will  coagulate. 

cow's  MILK  ^ 

Appearance,  Smell,  Taste. — When  milk  is  perfectly  fresh,  it  is 
a  white,  or  yellowish  white,  opaque  fluid.  It  separates  into  two 
distinct  layers,  when  it  is  allowed  to  stand  undisturbed  for  some 
time.  The  upper  and  Ughter  layer,  which  consists  largely  of 
globules  of  fat  and  is  called  "cream,"  is  yellower  than  the  lower 
layer,  which  is  white  or  bluish  white  and  is  known  as  "skimmed 
milk."  When  it  is  pure  and  fresh,  milk  has  either  a  faint,  insipid 
odor,  or  no  odor  at  all,  and  a  mild,  faintly  sweetish  taste. 

Microscopic  Appearance. — Like  human  milk,  it  contains  many 
minute  fat  droplets  suspended  in  the  form  of  an  emulsion.  There 
are  more  ultramicroscopic  particles  than  in  human  milk,  be- 
cause it  contains  a  larger  amount  of  casein. 

Specific  Gravity. — The  specific  gravity  of  the  fat  in  cow's  milk 
is  different  in  different  breeds  of  cattle  and  varies  between  0.922 
and  0.937.^  The  specific  gravity  of  whole  milk  varies  between 
1.028  and  1.035  at  15"  C.  (60°  F.).  Jenson  gives  1.027  to 
1.040. 

Reaction. — ^The  reaction  depends  either  on  the  carbon  dioxid 
and  acid  phosphates  ^  or  on  the  mono-  and  diphosphates  in  the 
milk.^  Cow's  milk  is  described  as  amphoteric  to  Htmus  paper.  On 
standing  exposed  to  the  air,  it  becomes  acid.  The  degree  of  the 
acidity  and  the  rapidity  of  the  change  depend  on  the  kind  and  on 
the  amount  of  bacterial  activity  by  which  milk  sugar  is  split  up 
into  lactic  acid.  Fresh  milk  has  been  studied  with  different  in- 
dicators and  it  has  been  found  that  100  c.  c.  of  milk  has  the  same 
alkaUne  reaction  toward  blue  htmus  as  41  c.  c.  of  N/10  caustic 
soda,  and  the  same  acid  reaction  toward  phenolphthalein  as  19.5 

1  Nilson:  Maly's  Jahrsber.  21. 

2  The  following  publications  are  drawn  from  freely  in  the  ensuing  section: 
E^tle  and  Roberts:  The  Chemistry  of  Milk  Hygiene,  Lab.  Bulletin  No.  56, 
Washington,  1909,  p.  315;  Jensen's  Milk  Hygiene,  Phila.  and  London,  1907, 
and  Voltz:  Chemie  der  Kuhmilch  in  Oppenheimer  Handbuch  der  Biochemie 
des  Menschen  und  der  Thiere,  vol.  iii,  first  half,  Jena,  1910,  386;  Hammarsten 
A  Textbook  of  Phys.  Chemistry,  N.  Y.,  1912;  Koeppe  and  Raudnitz  in  Som- 
merfeld's  Handbuch  der  Milchkunde,  Wiesbaden,  1909. 

*Heischmann:  Lehrbuch  der  Milchvirtschaft.,  Heinsiws  Machf.,  Bremen. 
*  Leach:  Food  Inspection  and  Analyses,  N.  Y.,  1907,  ii. 
'Richmond:  Analyst,  1900,  xxv,  121. 


COW'S  MILK.   CHEMISTRY  AND  BIOLOGY       159 

c.  c.  of  N/10  sulphuric  acid.*  Bahrdt  and  Edelstein  ^  did  not  find 
any  volatile  fatty  acids  in  either  fresh  cow's  or  human  milk.  When 
milk  is  allowed  to  stand,  the  volatile  fatty  acids  appear.  The 
average  hydrogen  ion  concentration  of  cow's  milk  is  2.6X10""^^ 
Cow's  milk  conducts  electric  currents  because  it  contains  dis- 
solved salts.  Fifty-eight  per  cent  of  the  molecules  of  the  mineral 
salts  in  cow's  milk  and  26%  in  human  milk  are  dissociated.* 

Quantily. — Since  the  quantity  of  milk  is  of  moment  only  to  the 
milk  producer,  it  will  not  be  considered  here. 

The  Coagulation  of  Cow's  Milk. — By  the  coagulation  of  cow's 
milk  is  meant  all  the  processes  concerned  in  the  precipitation 
of  casein, 

(a)  Effect  of  Adds  on  Coagulation  of  Milk. — Perfectly  fresh 
amphoteric  milk  does  not  coagulate  on  boiling,  A  peUicle,  con- 
sisting of  coagulated  casein  and  lime  salts,  is  formed  on  the  surface. 
This  re-forms  rapidly  after  being  removed.^  Fresh  milk  does  not 
coagulate  on  boiling,  even  after  a  current  of  carbon  dioxid  has 
been  passed  through  it.  As  milk  ages,  lactic  acid  begins  to  form 
and  a  stage  is  reached  in  which  milk,  which  has  previously  had 
carbon  dioxid  passed  through  it,  coagulates  on  boiUng,  At  a 
second  stage  it  coagulates  on  heating  without  the  treatment  with 
carbon  dioxid.  When  the  lactic  acid  is  present  in  sufficient  amount, 
the  milk  coagulates  spontaneously  at  room  temperature,  forming 
a  solid  mass.  The  amount  of  lactic  acid  formed  in  milk  depends 
both  upon  the  amount  of  sugar  in  the  milk  and  the  type  of  or- 
ganism. The  acidity  may  vary  between  0.3%  and  1.3%.  In 
most  instances,  when  a  vigorous  strain  of  organism  is  used,  the 
amount  of  lactic  acid  varies  between  0.5%  and  0.6%.^ 

Kastle^  studied  the  coagulation  of  sour  milk  in  Washington. 
His  results  are  given  in  Table  30  on  page  148. 

The  milk  which  coagulated  spontaneously  at  65°  C.  (145°  F.)  had 
an  acidity  of  0.711.  As  a  general  rule,  the  milks  which  are  most 
easily  coagulated  by  heat  have  the  highest  acidity.  On  the  other 
hand,  samples  of  milk  with  an  acidity  of  0.54%  of  lactic  acid,  which 
did  not  coagulate  on  boiling,  have  been  reported.*    Fresh  milk, 

^Conrant:  Uber  die  Reaction  der  Kuh  und  Frauenmilch.  Inaug.  Diss., 
Breslau,  1891,  9. 

*  Bahrdt  and  Edelstein:  Zeitschr.  f.  Kinderh.,  1914,  xi,  403. 
»  Clark:  Jour.  Med.  Research,  N.  S.,  1915,  xxvi,  431. 

*  Koppe:  Jahrb.  f.  Kinderh.,  1898,  xlvii,  389. 

*  Hammarsten:  he.  cit. 

*  Leischmann:  Bact.  acidi  lactid. 
^  Kastle  and  Roberts,  loc.  cit. 

*  Stokes:  Analyst,  xvi,  22. 


160       COW'S  MILK.   CHEMISTRY  AND  BIOLOGY 


according  to  Richmond/  has  an  acidity  of  20  degrees,  correspond- 
ing to  0.18%  lactic  acid.  He  found  that  milk  curdled  on  boiling 
when  it  had  an  acidity  of  33  degrees,  corresponding  to  0.29%  of 
lactic  acid. 

TABLE  30 

The  Relation  op  the  Acidity  and  the  Tempekatuke  op  Milk  to  Coagu- 
lation (Kastle) 


Acidity 

Temp. 

Time  of  heating, 

Curdled        =  + 

per  cent. 

°C. 

minutes 

Not  curdled  =  — 

0.711 

65 

0 

+  immediately 

.594 

65 

1 

+ 

.576 

65 

2 

+ 

.567 

65 

1 

+ 

.554 

60 

2 

+ 

.531 

65-67 

2 

+ 

.513 

65 

2 

+ 

.478 

60 

5 

+ 

.450 

65 

1J4 

+ 

.441 

66 

1 

+ 

.387 

65 

5 

+ 

.351 

65-67 

2 

+ 

.342 

78.5 

2 

+ 

.342 

66 

5 

— 

.315 

70 

10 

+ 

.315 

70 

5 

+ 

.306 

75 

3 

— 

.306 

65 

5 

— 

.288 

70 

5 

— 

.261 

65-74 

5 

'  — 

.252 

100 

1 

— 

.252 

70 

5 

— 

.243 

100 

1 

— 

.243 

72-74 

10 

— 

.243 

65 

10 

— 

.234 

65 

5 

+ 

.225 

65-67 

2 

.198 

65 

5 

— 

.180 

65 

5 

— 

(b)  Precipitation  with  Adds. — Casein  may  be  precipitated  from 
cow's  milk  by  dilute  acids.  It  requires  50  to  70  c.  c.  of  N/10  hy- 
drochloric acid,  or  60  to  80  c.  c.  of  N/10  acetic  acid  to  give  the  best 
results.  When  casein  is  treated  with  dilute  acids,  two  chemical 
reactions  take  place:  first  the  acid  combines  with  the  calcium  in  the 
casein,  forming  a  base-free  casein  or  a  casein  set  free  from  its 

*  Richmond:  Analyst,  1900,  xxv,  121, 


COW'S  MILK.   CHEMISTRY  AND  BIOLOGY       161 

combination  with  calcium;  on  the  addition  of  more  acid,  the  casein 
molecule  combines  directly  with  the  acid,  forming  a  salt  of  the 
acid.  This  action  is  hastened  by  an  increase  of  temperature. 
(Van  Slyke.) 

It  is  supposed  by  Van  Slyke  to  be  an  absorption  of  acid  by  the 
casein  while  Robertson  believes  that  the  acid  goes  in  combination 
with  the  casein.  Since  such  an  excess  of  acid  is  not  found  in  the 
physiology  of  the  infant,  casein  may  be  considered  as  having  the 
properties  of  an  acid  in  subsequent  discussions. 
An  excess  of  acid  will  redissolve  the  precipitate.^ 
(c)  Rennin  Coagulation.^'  ^ — The  following  are  some  of  the  more 
important  facts  in  reference  to  the  action  of  rennin  upon  milk 
casein  in  causing  coagulation: 

(I)  The  presence  of  soluble  lime  salts  appears  to  be  necessary 
for  the  coagulation  of  milk  by  rennin. 

(II)  The  reaction  must  be  neutral  to  litmus,  or  acid,  but  not 
alkaline.  Acids,  whether  organic  or  inorganic,  although  they  differ 
from  one  another  in  respect  to  the  intensity  of  the  influence  which 
they  exert  on  the  action  of  rennin,  all  have  a  very  marked  effect 
upon  the  coagulation  of  calcium  casein  by  rennin.  The  usual 
explanation  of  this  effect  of  acids  upon  the  action  of  rennin  is  that 
the  acid  which  is  added  dissolves  the  insoluble  calcium  phosphate 
of  milk  and  thus  increases  the  amount  of  soluble  calcium  salts. 
The  claim  is  also  made  by  some  that  the  acid  has  in  itself  some 
direct  influence  upon  the  action  of  rennin. 

(III)  The  dilution  of  milk  with  water  delays  the  coagulation 
of  milk  by  rennin,  because  the  proportion  of  soluble  calcium  salts  is 
decreased.  The  addition  of  calcium  chlorid  or  of  a  free  acid  to 
milk  diluted  with  water  not  only  hastens  the  time  of  coagulation, 
but  also  increases  the  amount  of  casein  coagulated. 

(IV)  Different  chemical  compounds  affect  the  coagulation  of 
milk  by  rennin  in  different  ways. 

(V)  The  addition  of  foreign,  inert  matter,  like  starch  or  saw- 
dust, hastens  rennin  action. 

(VI)  The  temperature  affects  the  rapidity  of  coagulation  of 
milk  by  rennin.  For  complete  action,  the  time  decreases  as  the 
temperature  increases.  In  a  given  time,  rennin  coagulates  milk 
most  completely  at  from  106°  to  108°  F.,  and  less  completely  at 
temperatures  above  and  below  this  point. 

*  Schlossmann  and  St.  Engel  in  Konig:  Der  mensch.  NShnmgs,  u.  Genua- 
mittel  II,  Berlin,  1914,  598. 

*  Van  Slyke:  Arch.  Pediatrics,  1905,  xxii,  515. 
»  Bosworth:  Jour.  Biol.  Chem.,  1913,  xv,  231. 


162       COW'S  MILK.   CHEMISTRY  AND  BIOLOGY 

(VII)  The  temperature  at  which  coagulation  takes  place  affects 
the  character  of  the  coagulum.  At  60°  F.  the  curd  is  flocculent, 
spongy  and  soft;  at  from  77°  to  113°  F.  it  is  more  or  less  firm  and 
solid;  at  122°  F.  and  above  it  is  very  soft,  loose  and  more  or  less 
gelatinous. 

(VIII)  Rennin  heated  for  some  time  to  over  140°  F.  becomes 
permanently  weaker  or  inactive.  It  is  somewhat  affected  at  about 
120°F.  Weak  solutions  are  more  easily  affected  by  an  increase  of 
temperature  than  are  strong  solutions. 

(IX)  An  increase  in  the  amount  of  rennin  in  proportion  to  the 
milk  hastens  the  rapidity  of  coagulation  as  does  also  an  increase  in 
the  strength  of  the  rennin. 

(X)  Freshly  drawn  milk  curdles  more  completely  than  it  does 
after  it  is  allowed  to  cool.  This  is  because  it  is  warmer  and  per- 
haps because  of  the  presence  of  carbon  dioxid. 

(XI)  Milk  heated  above  160°  F.  for  a  considerable  length  of 
time  coagulates  less  rapidly  than  unheated  milk.  The  coagulum  of 
heated  milk  is  highly  flocculent,  unless  soluble  calcium  salts  or 
some  acid  are  added  to  it.  Boiled  milk  is  not  coagulated  normally, 
if  at  all,  by  rennin. 

Hammarsten  was  the  first  to  show  that  the  coagulation  of  milk 
by  rennin  was  due  to  a  soluble  ferment  which  acted  directly  on  the 
casein,  producing,  as  he  thought,  two  substances,  the  insoluble 
curd  (Kase  or  paracasein),  and  a  soluble  product  whey-protein 
(Molkeneiweiss).  He  also  showed  that  the  change  of  casein  to 
paracasein  was  independent  of  coagulation,  the  coagulation  being 
due  to  the  presence  of  soluble  calcium  salts. 

A  great  number  of  papers  have  been  published  upon  this  subject 
since  the  early  work  of  Hammarsten.  As  his  explanation  of  the 
action  of  rennin  has  been  generally  accepted  as  correct,  most  of  the 
recent  investigations  have  been  concerned  with  the  influence  of 
the  soluble  salts  upon  the  coagulation.  These  investigations  have 
shown  that  the  soluble  salts  of  calcium,  barium  and  strontium 
favor  or  hasten  coagulation,  whUe  the  salts  of  ammonium,  sodium 
and  potassium  retard  or  inhibit  coagulation. 

Recently,  Van  Slyke  and  Bosworth  ^  have  shown  that  casein 
and  paracasein  are  acids  having  the  same  percentage  composition; 
that  the  molecular  weight  of  casein  is  probably  8,888,  while  the 
molecular  weight  of  paracasein  is  one-half  that  of  casein,  4,444; 
that  the  combinations  of  casein  with  barium  or  strontium  are 
insoluble  in  water  while  the  combinations  with  one  equivalent  of 
ammonia,  sodium,  or  potassium  are  soluble;  and  that  ammonium^ 
» Van  Slyke  and  Bosworth:  Jour.  Biol.  Chem.,  1913,  xiv,  203-236. 


COW'S  MILK.   CHEMISTRY  AND  BIOLOGY       163 

sodium  or  potassium  caseinates  can  be  changed  by  rennin  to  para- 
caseinates  which  are  soluble  and  are  precipitated  by  calcium 
chlorid  as  calcium  paracaseinates. 

These  facts  seem  to  indicate  three  things: 

First,  that  the  action  of  rennin  is  the  hydrolytic  splitting  of  the 
casein  molecule  into  two  similar  molecules  of  paracasein;  perhaps 
in  somewhat  the  same  manner  as  maltose  is  split  into  two  molecules 
of  dextrose. 

Second,  that  it  would  seem  doubtful  if  Hammarsten's  whey- 
protein  could  be  one  of  the  products  of  rennin  action. 

Third,  that  rennin  is  not,  strictly  speaking,  a  coagulating  fer- 
ment, the  coagulation  of  paracasein  being  due  to  the  fact  that  the 
calcium  paracaseinates  are  less  soluble  than  the  calcium  caseinates, 
especially  in  the  presence  of  the  soluble  salts  of  calcium,  barium  and 
strontium.  The  coagulation  is,  therefore,  a  secondary  effect,  the 
result  of  a  change  in  solubilities. 

The  curd  formed  in  the  coagulation  of  milk  contains  large 
quantities  of  calcium  phosphate.  Courant  ^  believes  that  calcium 
caseinate  on  coagulation  may  carry  down  with  it,  if  the  solution 
contains  dicalcium  phosphate,  a  part  of  this  as  tricalcium  phos- 
phate, leaving  monocalcium  phosphate  in  the  solution. 

When  the  phenomena  of  coagulation  of  milk  are  watched  under 
the  ultra-microscope  ^  the  small  particles  of  casein  are  seen  to 
clump  together  before  there  is  any  visible  gross  coagulation.  As 
more  and  more  particles  clump  together  they  become  visible.  The 
milk  of  fresh  cows  is  better  suited  to  rennin  coagulation  than  the 
milk  of  cows  that  are  nearly  dry. 

(d)  The  Effect  of  the  Addition  of  Alkalies  on  the  Curdling  of 
Milk. — It  is  necessary  to  bear  in  mind  the  following  facts,  when 
considering  the  action  of  alkalies  on  casein.  Bosworth  and  Van 
Slyke  ^  have  shown  in  a  pretty  series  of  experiments  that  "casein 
is  a  protein  showing  the  characteristic  property  of  an  acid,  in  that 
it  combines  with  metals  or  bases  to  form  compounds  known  as 
caseinates."  For  example,  the  compound  of  casein  containing 
the  largest  amount  of  a  monovolent  metal-like  sodium  could  be 
represented  by  the  formula  Nas  casein  (sodium  caseinate);  the 
corresponding  calcium  compound  is  Ca4  casein  (calcium  caseinate). 
It  has  not  been  definitely  settled  yet  which  particular  compound  of 
calcium  is  present  in  milk,  but  it  is  probably  either  tetra-calcium 
or  tricalcium  caseinate.      When  the  calcium  caseinate  of  milk  is 

*  Courant :  loc.  cit. 

*  Kreidl  and  Neumann:  Pfluger's  Arch,  1908,  123,  523. 
•Bosworth  and  Van  Slyke:  Am.  Jour.  Dis.  Child.,  1914,  vii,  298. 


164       COW'S  MILK.   CHEMISTRY  AND  BIOLOGY 

acted  on  by  rennin,  it  is  changed  into  another  compound  called 
calcium  paracaseinate.  As  the  result  of  this  action  one  molecule 
of  calcium  caseinate  is  split  into  two  molecules  of  calcium  paracase- 
inate. This  reaction  may  be  represented  in  the  following  formula: 
Ca4  caseinate  =  Ca2  paracaseinate  +  Ca2  paracaseinate.  Para- 
casein, like  casein,  possesses  acid  properties,  but  it  only  has  one- 
half  the  combining  power  of  casein.  Calcium  paracaseinate  Ls  less 
soluble  than  the  corresponding  calcium  caseinate  present  in  the 
milk  from  which  it  is  formed,  and,  therefore,  when  milk  curdles, 
it  is  precipitated  as  a  solid.  If  rennin  is  added  to  a  solution  of 
sodium  caseinate  the  caseinate  is  split  into  two  molecules  of  sodium 
paracaseinate,  but  no  precipitation  or  curdling  takes  place.  This 
is  explained  by  the  fact  that  sodium  caseinate  is  very  soluble.  If  a 
small  amount  of  a  soluble  calcium  salt  (calcium  chlorid)  is  added 
to  the  solution  of  sodium  paracaseinate,  curdling  occurs  at  once, 
the  curd  being  calcium  paracaseinate.  This  chemical  reaction 
may  be  illustrated  in  the  following  manner: 

Sodium  paracaseinate  (soluble)  -|-  calcium  chlorid  =  calcium 
paracaseinate  (insoluble)  +  sodium  chlorid.  The  following  table 
(Bosworth  and  Van  Slyke)  illustrates  the  effect  of  increasing 
amounts  of  sodium  citrate  on  the  coagulation  of  milk: 

TABLE  31 
Effect  of  Sodium  Citrate  on  the  Curdling  of  Milk  by  Rennin 


Grains  of  sod.  citrate 

Amt.  rennet  solution 

Minutes  required  for 

to  1  oz.  of  milk 

used  per  100  c.  c. 

milk  to  curdle 

0.0 

2. 

6 

0.20 

2. 

7^ 

0.40 

2. 

8K 

0.65 

2. 

11 

0.85 

2. 

31 

1.00 

2. 

37 

1.25 

2. 

47 

1.50 

2. 

62 

1.70 

2. 

not  curdled 

1.90 

2. 

not  curdled 

2.10 

2. 

not  curdled 

The  addition  of  increasing  amounts  of  sodium  citrate  to  milk 
lengthens  the  coagulation  time  of  the  milk  up  to  the  point  when  1.7 
grains  per  ounce  is  added,  after  which  the  milk  does  not  coagulate. 
In  actual  practice  the  addition  of  this  amount  prevents  the  forma- 
tion of  a  curd  in  the  infant's  stomach.     The  explanation  of  this 


COW'S  MILK,  CHEMISTRY  AND  BIOLOGY        165 

fact  is  that  the  sodium  replaces  some  of  the  calcium  in  the  caseinate 
and  forms  sodium  caseinate  of  calcium-sodium  caseinate.  When 
rennin  is  added  this  double  salt  is  changed  to  calcium  sodium 
paracaseinate,  which,  owing  to  the  presence  of  sodium,  is  not 
curdled. 

Ldme  Water. — "When  lime  water  is  added  to  cow's  milk  un- 
til it  is  neutral  or  faintly  alkaline  to  phenolphthalein,  a  basic 
calcium  casein  is  formed  which  is  not  acted  upon  by  rennet  and 
will  not  form  a  curd  even  in  the  presence  of  lime  salts."  ^  This 
results  from  the  precipitation  of  the  calcium  phosphate  in  the 
form  of  insoluble  di-  and  tricalcium  phosphate.  The  soluble  cal- 
cium phosphate  may  be  so  reduced  in  cow's  milk  by  this  pro- 
cedure that  there  is  less  than  is  present  in  human  milk.^  In  actual 
practice  the  addition  of  lime  water  to  milk  may  increase  its  alka- 
linity to  such  a  point  that  the  stomach  will  not  secrete  the  requisite 
amount  of  acid  to  make  the  stomach  contents  neutral  or  acid. 
A  neutral  or  acid  reaction  is  necessary  for  the  coagulation  of  milk 
by  rennin. 

Anti-rennin  may  be  formed  by  injecting  rennin  into  horses  until 
a  ferment  is  formed  which  destroys  the  action  of  rennin.^*  ^  When 
it  is  added  to  milk  with  rennin  it  prevents  the  coagulation  of 
milk. 

The  Chemical  Composition  of  Cow's  Milk. — The  individual 
food  components,  fats,  lactose,  proteins  and  salts  will  be  con- 
sidered separately  and  then  as  a  whole.  The  variations  in  the 
composition  of  the  milk  of  a  single  cow  is  only  of  slight  interest  in 
this  connection,  because  the  milk  used  in  infant  feeding  is  in 
almost  all  instances  mixed  milk. 

Nitrogenous  Bodies. — The  following  table,  compiled  by  Leach,  ^ 
gives  a  good  idea  of  the  average  amounts  of  the  various  food 
components  and  also  of  the  extreme  variations  in  their  per- 
centages: 

*  Van  Slyke:  Archives  of  Pediatrics,  xxii,  515. 

2  Bosworth  and  Bowditeh:  Jour.  Biol.  Chem.,  1917,  xxviii,  431. 
'  Hammarsten :  loc.  cit. 

<Morgenroth:  Centr.  Bakt.,  1900,  xxvi,  349;  Fuld  and  Spiro:  Zeitschr. 
phys.   Chem.,   1900,  xxxi,   132. 

*  Leach:  Food  Inspection  and  Analysis,  New  York,  1907.  Table  compiled 
from  Koenig's  Chemie  der  Menschlechen  Nahrungs  und  Genussmittel. 


166       COW'S  MILK,  CHEMISTRY  AND  BIOLOGY 

TABLE  32 


Cow's  milk 

Specific 
gravity 

Water 

Casein 

Albvr 
min 

Total 
protein 

Fat 

Lac- 
tose 

Ash 

Minimum 

Maximum 

Average 

1.026 
1.037 
1.031 

80.32 
90.32 

87.27 

1.79 
6.29 
3.02 

0.25 
1.44 
0.53 

2.07 
6.40 
3.20 

1.67 
6.47 
3.64 

2.11 
6.12 

4.88 

0.35 
1.21 
0.71 

Table  33  shows  how  much  the  composition  of  the  morning  and 
evening  milk  may  vary.  These  figures  are  the  average  from 
29.707  tests  of  milk  made  by  Droop  Richmond  in  England. 

TABLE  33 


Milking 

Fat 
per  cent. 

Lactose 
per  cent. 

Protein 
per  cent. 

Ash 
per  cent. 

Solids 
per  cent. 

Morning. .  . 
Evening. .  . 

3.44 
3.90 

4.71 
4.69 

3.43 
3.39 

0.74 
0.73 

12.34 
12.71 

Cows  of  different  breeds  give  milk  of  somewhat  different  com- 
position and,  although  it  was  supposed  that  cattle  from  mountain 
regions  gave  a  richer  milk  than  those  from  the  lowlands,  there  are 
many  exceptions  to  this  statement.^  The  Jersey  and  Guernsey 
breeds  give  a  rich  milk  and  the  Holstein  and  Ayrshire  cattle  are  apt 
to  give  a  milk  poorer  in  fat  but  this  is  more  suitable  for  infant 
feeding.  The  fat  globules  in  the  Jersey  milk  are  almost  three  times 
that  of  the  Holstein.  The  milk  of  different  individuals  of  the 
same  herd  and  species  vary  in  composition  and  it  is  fair  to  assimie 
that  the  production  of  rich  milk  is  distinctly  an  "individual  prop- 
erty that  is  due  to  the  physiological  peculiarities  of  the  gland 
cells  of  the  animal,  and  which  to  a  great  degree  is  hereditary." 
(Jensen.) 

Nitrogenous  Compounds. — The  total  nitrogenous  compounds 
are  given  by  Van  Slyke  as  3.2%  and  by  Babcock  as  3.8%.  The 
principal  proteins  are  casein  and  albumin,  or  insoluble  and  soluble 
proteins.  The  principal  soluble  proteins  are  lactalbumin  and  lac- 
toglobulin.  There  are  probably  other  substances  also,  but  little 
is  known  about  them.  The  figures  as  to  the  relation  of  the  casein 
to  the  soluble  nitrogenous  bodies  in  the  milk  vary  greatly,  being  all 
the  way  from  2.6:1  ^  to  8:1.^    The  average  according  to  Van  Slyke 

'  See  Jensen's  Milk  Hygiene,  Phila.  and  London,  1907. 

^  Van  Slyke:  Archives  of  Pediatrics,  1905,  xxii,  509. 

'  Stohmann:  Milch  und  Molkereiproducte  1898,  58,  quoted  by  Czemy  and 
Keller;  Hammarsten:  Jahresber.  f.  Thierchemie,  1896,  xxv,  206;  Schloss- 
mann: Verb.  d.  13  Vers.  d.  Gesellsch.  f.  Kinderh.  in  Frankfurt,  1896,  78. 


COW'S  MILK,  CHEMISTRY  AND  BIOLOGY        167 

is  3.6  parts  of  casein  to  one  part  of  soluble  protein.  (In  human 
milk  the  relation  is  approximately  1 :2.)  Table  32  shows  that  the 
amount  of  casein  and  albumin  in  cow's  milk  may  vary  materially. 

Casein. — Cow  casein  is  a  white  powder,  with  a  specific  gravity  of 
1.259.  It  causes  moist  blue  Utmus  paper  to  turn  red  and  shows  the 
characteristic  properties  of  an  acid,  in  that  it  combines  with  metals 
or  bases  to  form  compounds  known  as  caseinates.^  One  gram 
of  ash-free  casein  develops  5.742  calories  according  to  Schloss- 
mann; ^  5.85  according  to  Sherman.'  The  molecular  weight  of 
casein  is  8888.^  It  has  the  following  composition:  C.  53.0;  H.  7; 
N.  15.7;  S.  0.8;  P.  0.85;  O.  22.65%.2 

The  question  whether  the  casein  from  different  kinds  of  milk  is 
identical  or  whether  there  are  several  caseins  cannot  be  decided  by 
the  elementary  composition.^  It  is  probable  that  chemically  they 
are  much  the  same,  but  that  biologically  they  are  different.  (See 
Human  Casein.) 

Casein  dissolves  readily  in  water  with  the  aid  of  alkaU  or  alkaline 
earths,  also  calcium  carbonate  from  which  it  expels  carbon  dioxid. 
Such  solutions  are  precipitated  by  dilute  acids  and  redissolved  by 
stronger  acids  (s.  5-2.8  grams  HCl  to  10.0  grains  casein).  It  is 
insoluble  in  alcohol  and  water. 

The  casein  in  milk  is  in  combination  with  calcimn  in  the  form 
of  calcium  caseinate.  It  has  not  been  definitely  settled  as  yet 
which  particular  compound  is  in  milk,  but  it  is  probably  either 
tetra-calcium  or  tri-calcium  caseinate.* 

Osborne  and  Guest  "^  have  shown  by  hydrolysis  that  casein 
contains  glycocoll  0%,  alanine  1.5%,  valine  7.2%,  leucine  9.35%, 
proline  6.7%,  phenylalanine  3.2%,  glutaminic  acid  15.55%,  as- 
partic  acid  1.39%,  cystine  series  0.5%,  tyrosine  4.5%,  oxyproline 
0.23%,  histidine  2.50%,  arginme  3.81%,  lysine  5.95%,  trypto- 
phane 1.5%,  diaminotrioxy  dodecanic  acid  0.75%,  NHs  1-61%,  S. 
0.76%,  P.  0.85%.  The  figures  quoted  by  Raudnitz  *  vary  some- 
what from  these. 

Paracasein. — Paracasein  is  a  body  closely  related  to  casein. 
The  transformation  of  casein  into  paracasein  is  a  process  of  hy- 
drolytic  sphtting,  one  molecule  of  casein  yielding  two  molecules 

^  Bosworth  and  Van  Slyke:  Am.  Jour.  Dis.  Children,  1914,  vii,  298. 

*  Schlossmann:  quoted  by  Raudnitz  in  Sommerf eld's  Handbuch. 
'  Sherman:  Chemistry  of  Food  and  Nutrition,  N.  Y.,  1911,  123. 

*  Van  Slyke  and  Bosworth:  Jour.  Biol.  Chem.,  xiv,  1913,  231. 
'  Hammarsten:  Textbook  of  Phys.  Chem.,  N.  Y.,  1912,  615. 

*  Bosworth  and  Van  Slyke:  Am.  Jour.  Dis.  Children,  1914,  vii,  298. 
^  Osborne  and  Guest:  Jour.  Biol.  Chem.,  1911,  ix,  p.  333. 

*  Raudnitz:  Sommerf  eld's  Handbuch  der  Milchkinde,  Wiesbaden,   1909. 


168       COW'S  MILK,  CHEMISTRY  AND  BIOLOGY 

of  paracasein  ^  When  paracasein  is  in  combination  with  a  salt 
the  compound  is  known  as  the  paracaseinate  of  that  salt.  For 
instance  the  combination  with  calcium  is  known  as  calcium  para- 
caseinate. It  has  been  shown  above  that  calcium  paracaseinate 
is  insoluble,  while  sodium,  potassium  and  ammonium  paracase- 
inate are  soluble.  Calcium  paracaseinate  is  similar  to  calcium  case- 
inate,  but  it  cannot  be  recoagulated  by  rennin. 

Lactalbumin. — Lactalbumin,  one  of  the  components  of  whey 
protein,  has  the  following  composition:  C.  52.19,  H.  7.18,  N.  15.77, 
S.  1.73,  O.  23.13%.^  When  compared  to  casein,  the  most  strik- 
ing differences  are  that  it  contains  more  sulphur  and  no  phos- 
phorus. 

Lactoglobulin. — Lactoglobulin  is  very  similar  in  its  composition 
to  serum  globuHn.  It  is  present  in  only  small  amounts  in  normal 
milk,  but  in  larger  amounts  in  colostrum.^ 

Extractives. — There  are  traces  of  urea,  creatine,  creatinine, 
hypoxanthine  (?)  and  cholesterine  in  cow's  milk.^ 

Whey. — ^Whey  is  an  opalescent  solution  which  remains  after  the 
coagulation  of  casein.  It  contains  lactalbumin,  lactoglobulin  and 
extractives.  Most  of  the  sohd  portion  of  the  whey  of  cow's  milk  is 
lactalbumin,  while  the  rest,  a  small  part,  is  divided  among  the 
other  components.  Although  the  analyses  of  whey  are  essentially 
the  same  as  the  analyses  of  lactalbumin,  they  are  reported  in  a 
separate  paragraph.  The  whey  from  cow's  milk,  according  to 
Konig  ^  contains:  water  93.8%,  total  ash  0.44%.  The  ash  con- 
tains K2O  30.77%,  Na20  13.75,  CaO  19.25,  Mg.  0.036,  r203  0.55, 
P2O5  17.05,  SO3  2.73,  CL  15.15. 

Fat. — The  percentage  of  fat  in  the  mixed  milk  of  herds  may  be 
maintained  at  4%  by  carefully  testing  and  selecting  the  cows.  It  is 
such  4%  milk  that  should  be  used  in  infant  feeding.  The  problems 
incident  to  maintaining  the  percentage  of  fats  at  the  required 
amount  do  not  concern  the  pediatrician,  and,  therefore,  will  not  be 
considered. 

The  fat  droplets  are  exceedingly  small.  Their  diameter  varies 
from  0.0024  to  0.0046  m.  m.  There  are  1.06  to  5.75  millions  of  fat 
drops  to  the  cubic  m.  m.^  It  is  possible  that  the  fat  droplets  are 
maintained  in  a  state  of  emulsion  because  they  are  surrounded 
by  a  covering  of  casein  which  prevents  the  globules  from  uniting 

«  Bosworth:  Jour.  Biol.  Chem.,  1914,  xix,  397. 

'  Sebelien:  quoted  by  Voltz  in  Oppenheimer's  Handb.  loc.  dt.,  p.  390. 

«Hammersten:  Textbook  of  Phys.  Chem.,  N.  Y.,  1912. 

'  Konig:  loc.  dt. 

*Woll:  Wisconsin  Exp.  Station,  vi,  1892. 


COW'S  MILK,  CHEMISTRY  AND  BIOLOGY       169 

with  one  another,^  or  that  they  are  surrounded  by  a  membrane.^ 

The  fat  of  cow's  milk  is  chiefly  of  olein  and  pahnitin.  It  also 
contains  triglycerides,  butyric  acid,  myristic  acid,  stearic  acid, 
small  amounts  of  lauric  acid,  arachidic  acid  and  dioxystearic  acid, 
as  well  as  caproic  acid,  traces  of  capryUc  acid  and  capric  acid.' 
The  fat  of  milk  contains  small  quantities  of  lecithin,  cholesterin, 
and  a  yellow  coloring  matter.  This  yellow  coloring  matter,  accord- 
ing to  Palmer  and  Eckles  *  is  carotin  and  xanthophyll,  especially 
the  former  which  is  a  well  known  yellow  vegetable  pigment  found 
accompanying  chlorophyll  in  all  green  plants.  The  pigment  comes 
from  the  food,  especially  green  grass.  It  is  possible  that  the  qual- 
ity of  the  food  may  influence  the  composition  of  the  fat. 

Lactose. — Milk  sugar  is  easily  soluble  in  water  and  does  not 
ferment  with  pure  yeast.  The  extreme  variations  in  the  per- 
centage of  milk  sugar  in  cow's  milk  are  2.11%  and  6.12%,  the 
average  being  4.88%,^  according  to  some  authors,  and  4.60% 
according  to  others.  ^ 

Lecithin. — Cow's  milk  contains  between  0.048  gm.  and  0.058  gm. 
of  lecithin.' 

Some  investigators  maintain,  however,  that  these  figures  repre- 
sent a  mixture  of  lecithin  and  kephalin.* 

Salts. — The  total  ash  in  cow's  milk  is  generally  given  as  0.7%, 
the  extreme  limits  being  0.6%  and  1.0%.^ 

'  Quincke:  Pfluger's  Arch.  xix. 

2  Abderhalden  and  Voltz:  Sfeitschr.  f.  phys.  Chem.,  lix. 

'  Hammarsten:  loc.  cU. 

•  Palmer  and  Eckles:  Jour.  Biol.,  Chem.,  1914,  xvii,  191. 
^  Leach:  loc.  cit. 

•  Fleischmann:  Lehrbuch  der  Milchwirtschaft,  Bremen,  1898,  xi,  43,  quoted 
by  Czemy  and  Keller,  I,  437. 

">  Bunge:  Zeitschr.  f.  Biologie,  1874,  x,  309. 

8  Schloss:  iJber  Sauglings-Emahrung,  Berlin,  1912,  65. 

•  Soldner:  Die  Landwirthsch.  Versuchstat,  1888,  xxxv,  361,  quoted  from 
Voltz  in  Oppenheimer's  Handbuch,  III,  I,  398. 


170       COW'S  MILK.   CHEMISTRY  AND  BIOLOGY 

TABLE  34 
Percentage  of  Salts  in  Cow's  Milk  in  100  Parts  op  Ash 


AbdcT' 

Rich- 

Bunge ^ 

halden^ 

Schloss ' 

Soldner 

Pdka-^ 

mond  * 

K20 

22. U 

22.40 

24.74 

24.96 

23.75 

28.71 

NajO 

13.91 

12.25 

10.79 

6.16 

15.36 

6.67 

CaO 

20.05 

21.07 

21.35 

22.25 

20.37 

20.27 

MgO 

2.63 

2.91 

2.71 

2.71 

2.80 

FezOj 

0.04 

.40 

P2O8 

24.75 

24.10 

29.54 

32.27 

27.13 

29.33 

(CL) 

21.27 

17.25 

13.63 

10.86 

14.67 

14.00 

One  liter  of  cow's  milk  contains  in  grams: 


Soldner » 

Schloss  2 

K20 

1.72-1.885 

0.51-0.465 

1.98-1.72 

0.20-0.205 

1.82-2.437 

0.98-0.82 

1.849 

NajO 

0.861 

CaO 

1.650 

MgO 

0.215 

P2O6 

2.183 

CL 

1.091 

100  grams 

of  the  Ash  of  Cream  contains  in  grams:  ^ 

K2O 

25.97 
9.86 

20.54 
4.20 

30.23 

16.15 

NazO 

CaO 

MgO 

PjOs 

CL 

Citric  Acid. — Cow's  milk  contains  about  0.2%  of  citric  acid.® 
Milk  conducts  electric  currents  because  of  the  presence  of  salts 
of  various  kinds.  The  electrical  conductivity  of  cow's  milk  is 
43.8.11-4,  and  of  human  milk  22.6.10-4.^  Koeppe  concludes  from 
these  figures  that  58%  of  the  molecules  in  cow's  milk  and  26%  of 
those  in  human  milk  are  dissociated. 

»  Bunge:  Zeitschr.  f.  Biologie,  1874,  x,  309. 
2  Schloss:  tjber  Sauglings-Emahrung,  Berlin,  1912,  55. 
'  Soldner:  Die  Landwirthsch.  Versuchstat.  1888,  xxxv,  361,  quoted  from 
Voltz  in  Oppenheimer's  Handbuch,  III,  I,  398. 

*  Richmond:  Dairy  Chemistry,  Phila.,  1899. 

*  Schloss:  loc.  cil. 

«  Soldner:  Zeitschr.  Biol.,  1896,  xxxiii,  43,  535. 
^  Koeppe:  Jahrb.  f.  Kinderh.,  1898,  xlvii,  389. 


COW'S  MILK.   CHEMISTRY  AND  BIOLOGY       171 

FROZEN   MILK 

Very  little  is  known  as  to  the  chemical  changes  which  take  place 
in  milk  when  it  is  frozen.  It  is  supposed  by  some  investigators 
that  the  casein  is  changed  by  the  freezing  into  a  more  permanent 
compound.^  Mai  ^  concluded,  however,  that  the  freezing  and 
thawing  of  milk  causes  no  permanent  change  in  its  composition. 

Pennington  ^  and  her  collaborators  found  very  definite  changes 
in  milk  after  freezing.  They  found  that  when  the  milk  is  held  at  a 
temperature  of  0°  C.  (length  of  time  not  stated),  there  is  pro- 
teolysis of  the  casein,  which  is  primarily  of  bacterial  origin,  and 
proteolysis  of  the  lactalbumin,  due  primarily  to  the  native  enzymes 
of  the  milk.  The  action  of  these  two  agents  together  is  more 
rapid  than  that  of  either  agent  alone.  The  bacteria  and  enzymes 
may  break  down  the  true  protein  and  carry  the  breaking  down 
through  peptones  even  to  amino  acids.  There  is  a  fermentation  of 
lactose  with  the  formation  of  lactic  acid,  which  is  largely,  if  not 
exclusively,  due  to  bacterial  action.  The  fat,  so  far  as  can  be 
determined,  is  not  affected  except  by  the  action  of  bacteria. 

Some  bacteria  disappear  from  the  milk  while  it  is  frozen,  while 
others  may  increase  rapidly,  especially  if  the  milk  is  raw.  The 
rate  of  increase  in  the  number  of  bacteria  depends  upon  their 
previous  surroundings  and  upon  the  rapidity  with  which  they 
become  acclimated  to  their  surroundings.  There  is  apt  to  be  very 
little  increase  in  the  first  four  or  five  days,  after  which  there  is  a  very 
rapid  increase  in  numbers.  There  is  no  information  concerning 
the  chemical  changes  which  take  place  in  milk  that  has  been  frozen 
from  only  twenty-four  hours  to  forty-eight  hours.  The  predomin- 
ating organisms  which  they  found  were  the  micrococcus  aurantia- 
cus  (Cohn),  and  the  micrococcus  ovalis  (Escherich)  both  of  which 
belong  to  the  acid  forming  group. 

^  Engling:  Landw.  Vers.  Stat.,  1888,  xxxi,  391 ;  Siegfried  and  Bischoff :  quoted 
by  Raudnitz  in  Sommerf eld's  Handbuch,  201. 

*  Mai:  Z.  Nahr.  Genussm.,  xxiii,  250  from  chemical  abstr.,  Sept.  20,  1912. 

'  Pennington,  Hepburn,  Witner,  Stafford  and  Burrell:  Jour,  of  Biol.  Chem., 
1913,  xvi,  331.  See  also  Pennington:  Jour.  Biol,  Chem.,  1908,  iv,  353;  Hep- 
bum:  Jour,  of  the  Franklin  Ins.,  1911,  cbcdi,  187. 


172       COW'S  MILK.   CHEMISTRY  AND  BIOLOGY 


TABLE  35 

COBIPAKATIVE  COMPOSITION  OP  MiLKS  OF  DIFFERENT  AnIMALS  TaKEN  FROM 

VOLTZ  1 


MUk 


Total 

Water 

Solids 

Fat 

Casein 

N. 

Sugar 

87.58 

12.42 

3.74 

0.80 

2.01 

6.37 

87.80 

12.20 

3.40 

2.70 

3.40 

4.70 

82.30 

17.70 

7.70 

4.80 

4.40 

86.13 

13.87 

4.80 

3.03 

5.34 

86.55 

13.45 

3.15 

3.00 

3.90 

5.60 

87.60 

12.40 

5.38 

2.98 

3.26 

86.30 

13.70 

4.00 

3.60 

4.60 

4.30 

81.50 

18.50 

7.00 

4.30 

5.60 

5.00 

67.70 

32.30 

17.10 

10.90 

2.80 

90.58 

9.42 

1.14 

2.50 

5.87 

90.12 

9.88 

1.37 

0.79 

1.85 

6.19 

67.85 

32.15 

19.57 

3.09 

8.84 

90.43 

9.57 

4.51 

69.50 

30.50 

10.45 

15.54 

1.95 

41.11 

58.89 

45.80 

11.19 

1.33 

77.00 

23.00 

9.26 

4.15 

9.72 

3.11 

81.64 

18.36 

3.33 

3.11 

9.53 

4.91 

82.37 

17.63 

6.44 

6.09 

4.04 

50.47 

39.53 

20.00 

12.42 

5.63 

Ash 


Human 

Cow 

Buffalo 

Zebu  (1  analysis).. 
Lama  (3  analyses. 
Camel  (7  analyses) 

Goat 

Sheep 

Reindeer 

Mare 

Donkey 

Elephant 

Hippopotamus 

(1  analysis) 

Rabbit 

(1  analysis) 

Guinea  pig 

(1  analysis) 

Dog  (8  analyses) . . 

Cat 

Pig 

Blue  Whale 


0.32 

0.7» 

0.8* 

0.7" 

0.8« 

0.77 

0.88 

0.9« 

1.50  »•> 

0.36" 

0.47  »2 

0.66  i» 


2.56" 

0.571* 
0.91  i« 
0.59" 
0.591* 

1.48  19 


^  Oppenheimer's  Handbuch  der  Biochemie,  iii,  Jena,  1910,  403. 

2  J.  Konig:  D.  mensch.  Nahrungs  u.  Genussmittel  1904,  Berlin,  ii,  598. 

'  Kirschner:  Hand.  d.  Milchwirtschaft,  Berlin,  1907,  pp.  7  and  40. 

*Kirschner  (see  above). 

^  Konig  (see  above). 

*  Konig  (see  above). 

^  Barthe:  quoted  in  Malys  Jahresber.,  1906,  230. 

*  Kirschner  (see  above). 
'  Kirschner  (see  above). 

1"  Fleischmann:  Lehrb.  d.  Milchwirtschaft,  3rd  ed.,  Leipzig,  1901,  67. 
^^  Kirschner  (see  above). 
12  Kirschner  (see  above). 
1*  Hammarsten. 
1*  Konig  (see  above). 
"  Konig  (see  above). 

"Konig  (see  above).     See  also  Gruinner,  Biochem.  Zeitschr.,  1915,  Ixviii, 
311. 

"Camaille,  C.  R.  63,  692. 

"  Hammarsten. 

»  Backhans  quoted  in  Maly's  Jb.  1906,  299. 


COW'S  MILK.   CHEMISTRY  AND  BIOLOGY       173 

Rosenau  ^  found  that  freezing  milk  for  forty-eight  hours  did  not 
influence  its  restraining  action  on  the  growth  of  the  typhoid  bacil- 
lus, but  destroyed  it  for  the  B.  lactis  aerogenes. 


GOAT'S  MILK 

Goats  are  seldom  infected  with  tuberculosis.^  This  does  not 
mean,  however,  that  they  are  immune  and  never  have  the  disease. 

The  goat  may  secrete  ten  times  its  own  weight  in  milk  in  a 
year's  time.^  It  produces  the  most  milk  during  the  hot  summer 
months. 

The  composition  of  goat's  milk  as  given  by  various  authors  is 
as  follows: 

TABLE  36 


Voelcker ' 

Per  cent. 

Ellen- 

Hucho  5 

Abder- 

Ander- 

Schaf- 

Steineg- 

of 

burger  * 

halden^ 

1 

7.02 

2 

7.11 

3 

egg^ 

fer^ 

ger 

Fat 

6-7 

2.50- 

2.93 

7.34 

4.6 

2.14- 

3.25 

5.10 

4.72 

Lactose 

4.5 

3.76- 
5.46 

3.92 

5.28 

4.68 

5.99 

4.3 

2.07- 

4.77 

2.80 

Casein 

2.8 

2.56 

Albumen .... 

0.51 

0.58 

1.03 

Total  protein. 

3.35 

2.25- 
3.89 

3.14 

4.67 

3.94 

3.19 

3.5 

2.3- 
4.38 

3.92 

Ash 

0.895 

0.72- 
0.98 

1.01 

0.79 

0.77 

0.51- 
0.93 

0.63 

0.63 

The  composition  of  goat's  milk  is  very  similar  to  that  of  cow's 
milk.  It  is  different,  however,  in  that  it  is  pure  white  instead  of 
golden  white  in  color.  Goat's  milk  has  a  characteristic  odor  when 
it  is  milked  in  the  stable  and  the  odor  of  the  animals  pervades  the 
air.  This  odor  is  more  marked  when  the  male  is  present  in  the 
same  stall  as  the  female. 

The  fat  drops  in  goat's  milk  are  somewhat  smaller  than  those  in 

^Rosenau:  Hygienic  Laboratory,  Bulletin  No.  56,  Washington,  1909,  487. 
*Richter:  Berhner  khn.  Wochenschr.,  1888,  No.  18;  Schwartz:  Deutschr. 
med.  Wochenschr.,  1896,  No.  40. 

»Fleischmann:  Lehrbuch  d.  Milchwirtschaft,  2nd  ed.,  1898,  65  (C.  &  K.). 

*  Ellenburger:  Arch.  f.  physiol.,  1899,  p.  48. 

^  Hucho:  Yahresber  f.  physiol.  Chemie,  1899,  xxvii,  440. 

•  Abderhalden :  Zeitschr.  f.  physiol.  Chemie,  1899,  xxvii,  440. 
'Voelcker:  Milchzeitung,  1881,  x,  151  (3  goats). 
«Anderegg:  Sandw.  Wochenbl.,  1893,  xix,  290  and  330  (C.  &  K.). 
•Schafifer:  Schweizer,  Wochenschr.,  f.  Pharmacie,  xxxi,  58  (C.  &  K.). 


174       COW'S  MILK.   CHEMISTRY  AND  BIOLOGY 

cow's  milk.  The  casein  coagulates  more  quickly  with  reirnin  than 
does  that  of  cow's  milk.^  The  casein  precipitates  out  in  compact 
masses,  which  are  colored  white  and  have  a  fine  structure.  When 
this  casein  undergoes  pepsin-hydrochloric  acid  digestion,  12%  re- 
mains undigested. 

Konig  ^  found  the  average  composition  and  the  extreme  varia- 
tions in  100  analyses  to  be  as  follows: 


TABLE  37 

Average 

Variations 

Water 

86.88  % 
4.07  % 
4.63  % 
3.76  % 
0.85  % 
1.030% 

82.02  -90.16% 

Fat 

2.29  -  7.55% 

Lactose 

2.80  -  5.72% 

Protein 

3.32  -  6.50% 

Ash 

0.35  -  1.36% 

Specific  gravity 

1.028-  1.036% 

The  composition  of  goat's  milk  is  influenced  by  the  same  factors 
and  in  the  same  manner  as  cow's  milk. 


1  Devarda:  Landw.  Versuchsst.  xlvii,  416;  Steinegger:  Milch  Ztg.,  1898, 
No.  23.    Quoted  by  Burr  in  Sommerfeld, — loc.  cU. 

«  Konig:  Molkerei-Ztg.  Hildesheim,  1897,  pp.  617,  635,  653. 


CHAPTER  XIV 
COW'S  MILK:  BACTERIOLOGY  AND  CHEMICAL  TESTS^ 

There  are  two  types  of  bacteria  found  in  milk,  the  non-patho- 
genic and  the  pathogenic.  The  ideal  milk  would  be  one  which  con- 
tained no  bacteria  but  this  is  very  difficult  to  obtain  because  bac- 
teria find  their  way  into  the  udder  through  the  opening  in  the  teat. 
These  bacteria  are  washed  out  in  the  fore-milk  which  is  rejected 
for  this  reason,  by  those  producing  clean  milk. 

The  commonest  bacteria  in  milk  are  those  producing  souring, 
of  which  the  lactic  acid  bacteria  are  the  most  common.  These  bac- 
teria produce  so  much  acid  in  the  milk  that  they  gradually  crowd 
out  other  organisms  which  cannot  grow  in  the  acid  surroundings. 
Lactic  acid  bacteria  are  not  found  in  milk  when  it  leaves  the  udder, 
but  enter  the  milk  when  it  is  exposed  to  air.  The  commonest  lac- 
tic acid  forming  bacteria  are  the  Bacillus  lactis  acidi  or  Streptococ- 
cus lacticus.  They  grow  best  in  anaerobic  media.  A  less  conmion 
form  is  the  B.  lactis  aerogenes. 

Of  the  bacteria  which  may  produce  disease  in  man  and  cause 
souring  of  milk,  the  colon  bacillus  is  common.  It  is  derived  from 
the  manure  of  the  cow.  Streptococci,  which  cause  inflammation 
of  the  udder  of  the  cow,  may  sour  the  milk  and  cause  disease  in 
those  drinking  it.  There  are  some  one  hundred  varieties  of 
bacteria  which  may  lead  to  lactic  acid  fermentation  and  souring 
of  milk. 

The  class  of  organisms  known  as  putrefactive  bacteria  may  im- 
part a  bad  odor  to  the  milk  and  cause  diarrhea  in  children  either 
through  their  own  action  or  by  the  products  of  their  activity. 
They  enter  the  milk  in  manure  and  filth.  They  may  liquefy  and 
digest  casein. 

Another  group  of  bacteria  apparently  has  no  action  on  the  milk 
and  is  not  harmful  to  the  consumer. 

Butyric  acid  bacteria  form  butyric  acid  by  splitting  up  the  fat  in 
rancid  butter.  Yellow,  red,  blue,  brown  and  green  milk  are  rarely 
seen  and  the  particular  coloration  is  due  to  changes  produced  in 
the  milk  by  special  bacteria.    A  turnip  taste  is  often  given  milk  by 

*  Window:  The  Production  and  Handling  of  Clean  Milk,  New  York,  1909, 
has  been  freely  used  in  this  section. 

175 


176  COW'S  MILK,  BACTERIOLOGY 

the  B.  foetidus  lactis.  Slimy  milk,  and  bitter,  stringy,  and  soapy 
milk  are  due  to  other  special  bacteria.  Bitter  milk  may,  however, 
be  produced  by  other  causes  than  the  growth  of  bacteria,  as  by 
certain  foods  which  the  cow  may  eat  (lupines,  ragweed,  wormwood, 
cabbages,  raw  Swedish  turnips).  Inflammation  of  the  udder  or 
garget  may  also  cause  the  milk  to  be  bitter. 

Red  milk  may  be  due  either  to  blood  or  the  cow's  eating  large 
amounts  of  sedges,  rushes,  madder  root,  alkalet,  field  horsetail, 
meadow  saffron,  and  knot  grass.  A  red  yeast  may  cause  the  cream 
to  turn  pink  after  standing  two  days. 

SUmy  milk  may  be  due  to  pus  or  to  the  B.  lactis  viscosus,  which 
comes  chiefly  from  water  and  dust. 

Pathogenic  Bacteria  in  Cow's  Milk.^ — The  tubercle  bacillus  is 
found  frequently  in  cow's  milk  when  the  animal  is  affected  with 
tuberculosis  of  the  udder.  It  is  also  found  in  milk  when  the  udder 
is  healthy  and  there  is  disease  in  other  parts  of  the  body,  viz., 
the  bowel  or  uterus,  the  excretions  of  which  fall  into  the  milk. 
The  secretion  from  a  diseased  lung  is  swallowed  and  may  be  spat- 
tered into  the  milk  pail.  The  tubercle  bacillus  may  also  get  into 
milk  from  consumptives  who  are  working  around  the  cattle,  either 
from  their  hands  or  expectoration. 

Theobald  Smith  ^  and  others  have  shown  that  there  is  a  differ- 
ence between  the  human  and  bovine  type  of  the  tubercule  bacillus. 
Recent  pathological  investigations  show  that  the  bovine  type  of 
the  tubercle  bacillus  may  be  the  cause  of  tuberculosis  in  human 
beings,  especially  in  the  infant  and  young  child.^ 

Other  pathogenic  bacteria  which  may  grow  in  milk  and  have 
been  the  etiological  cause  of  epidemics  are  the  typhoid  bacillus,  the 
diphtheria  bacillus,  the  streptococcus,  and  the  organism  that  causes 
scarlet  fever.  The  milk  is  usually  infected  after  it  has  been  milked 
by  the  hands  of  the  milker,  the  air  and  dust  in  the  stable,  the  milk 
pail,  the  water  supply,  the  milk  cooler,  cans  or  bottles.  The 
organisms  get  into  the  milk  from  the  outside. 

Other  organisms  which  have  not  been  reported  as  the  cause  of 
epidemics,  but  which  are  of  pathological  significance  in  cow's  milk 
are  the  dysentry  bacillus  (both  Shiga  and  Flexner  types),  the  gas 
bacillus,  the  staphylococcus,  bacteria  of  the  colon  group,  the 

^  Weber,  A. :  In  Sommerfeld's  Hand,  der  Milchkunde,  Wiesbaden,  1909, 
405,  is  used  freely  in  this  section.  The  original  may  be  consulted  for  the 
literature. 

^  Smith,  Theobald:  U.  S.  Dep't  Agric.  Bureau  of  Animal  Ind.,  12  and  13, 
Washington,  1897;  Jour.  Exp.  Med.,  1893,  iii. 

*  Von  Behring  and  Smith,  T. :  British  Royal  Commission  on  Tuberculosis^ 


COW'S  MILK:  BACTERIOLOGY  177 

bacillus  of  anthrax,  actinomyces,  and  the  organisms  of  cow  pox, 
hydrophobia,  foot-and-mouth  disease  and  cholera. 

"Milk  sickness"  ^  is  a  disease  of  sparsely  settled  conmiunities 
which  has  been  described  only  in  America.  It  is  due  to  a  motile 
rod  with  flagella,  the  Bacillus  lactimorbi,  which  has  been  demon- 
strated by  Jordan  and  Harris.^  In  cattle  it  causes  the  disease 
known  as  "trembles."    It  is  very  fatal  to  man. 

The  bacillus  of  contagious  abortion  ^  is  practically  always  pres- 
ent in  artificial  milk  produced  around  San  Francisco,  but  it  is 
not  pathogenic  to  infants.^  Whether  it  has  any  connection  with 
abortion  miscarriage  in  the  human  is  as  yet  unknown.  Larson 
and  Sedgwick  ^  have  found  that  the  blood  of  many  women  who 
have  aborted  gives  the  complement  fixation  test  to  the  Bacillus 
abortus  as  does  the  blood  of  many  children. 

Caloric  Value  of  Milk. — It  is  obvious  that  the  caloric  value 
of  milk  depends  upon  its  composition.  Since  the  composition  of 
cow's  milk  varies  considerably  the  caloric  value  also  varies.  The 
figures  most  generally  accepted  are  those  of  Rubner  who  found 
that  1000  grams  of  milk  gave  between  622  and  690  calories. 
Heubner  uses  670  calories  as  the  average  caloric  value  of  cow's 
milk. 

Milk  Preservatives.^ — The  most  commonly  used  preservatives 
are  formaldehyde,  borax  and  boric  acid.  Occasionally  saHcylic 
acid  and  sodium  carbonate  are  employed. 

Formaldehyde  may  be  detected  in  milk  in  the  following  man- 
ner: Place  about  twenty  cubic  centimeters  of  milk  in  a  small  glass 
vessel,  dilute  with  an  equal  volume  of  water,  and  add  commercial 
sulphuric  acid,  allowing  it  to  flow  slowly  down  the  inside  of  the 
vessel.  If  formaldehyde  is  present  a  purple  color  wiU  appear  at 
the  junction  of  the  acid  and  milk. 

Boric  acid  or  borax  are  detected  by  adding  a  drop  or  two  of 
hydrochloric  acid  to  a  few  drops  of  milk  in  a  white  dish  and  then 
several  drops  of  a  saturated  alcoholic  solution  of  turmeric.  The 
dish  is  then  heated  gently  for  a  few  minutes  and,  if  boric  acid  or 
borax  are  present,  a  pink  or  dark  red  color  will  appear.    A  dark 

1  McCoy:  Treasury  Dep't,  Hygienic  Laboratory  Bull.  56,  Wash.,  1908, 
217. 

''Jordan  and  Harris:  Jour.  A.  M.  A.,  1908,  L.  1665. 

'  Fabyan:  Jour,  of  Med.  Research,  xxvi.  No.  3;  xxviii,  No.  1;  Larson:  Jour. 
Inf.  Dis.,  1912,  178. 

*  Fleischner  and  Meyer:  Am.  Jour.  Dis.  Ch.,  1917,  xiv,  157. 

*  Larson  and  Sedgwick:  Am.  Jour.  Dis.  Cliildren,  1913,  vi,  326. 

*  Taken  from  K.  Winslow:  The  Production  and  Handling  of  Clean  Milk, 
N.  Y.,  2nd  Edition,  1909. 


178  COW'S  MILK:  BACTERIOLOGY 

blue-green  should  appear  when  the  dish  is  cooled  and  a  drop  of 
ammonia  added. 

Sodium  carbonate  is  detected  by  adding  an  equal  volume  of 
alcohol  and  then  two  drops  of  a  1%  solution  of  rosolic  acid  to  the 
suspected  sample  of  milk.  If  sodium  carbonate  is  present  a  red- 
rose  color  will  appear.  The  test  may  be  performed  with  more 
certainty  if  a  control  test  is  made  at  the  same  time  with  a  sample 
of  milk  known  to  be  pure. 

SaKcylic  acid  is  rarely  used  as  a  preservative.  It  may  be  de- 
tected by  adding  a  few  drops  of  sulphuric  acid  to  a  small  quantity 
of  milk  and  then  shaking  gently  with  a  mixture  of  equal  parts  of 
ether  and  petrolic  ether.  Equal  volumes  of  acidulated  milk  and 
the  ether  mixture  should  be  taken.  The  upper  ethereal  solution  is 
poured  off  after  standing  for  several  hours  and  the  remaining 
liquid  is  evaporated  in  a  porcelain  dish.  A  few  drops  of  water  and 
a  drop  of  ferric  chlorid  solution  will  produce  a  violet  or  purple 
color  on  being  added  to  the  solution  if  salicylic  acid  is  present. 

Babcock  test  (see  page  229). 

Estimation  of  total  solids  (see  page  229). 


CHAPTER  XV 

STERILIZATION,  BOILING  AND  PASTEURIZATION  OF 

MILK 

The  term,  "sterilization,"  should  never  be  applied  to  the  proc- 
essses  used  in  the  preparation  of  milk  for  the  feeding  of  infants, 
because  the  milk  is  never  rendered  bacteriologically  sterile  by 
them.  The  term  "pasteurization,"  as  it  is  ordinarily  used,  is 
indefinite  and  misleading.  It  should  always  be  stated  at  what 
temperature  the  milk  is  heated  and  how  long  it  is  kept  at  this 
temperature;  otherwise,  it  means  nothing.  In  Massachusetts 
pasteurized  milk  is  defined  by  law  to  be  natural  cow's  milk  not 
more  than  seventy-two  hours  old  when  pasteurized,  subjected  for 
a  period  of  not  less  than  thirty  minutes,  to  a  temperature  of  not 
less  than  one  hundred  and  forty  degrees  nor  more  than  one  hun- 
dred and  forty-five  degrees  Fahrenheit,  and  immediately  there- 
after cooled  therefrom  to  a  temperature  of  fifty  degrees  Fahren- 
heit or  lower. 

THE  CHANGES  PRODUCED  IN  MILK  BY  HEAT 

Appearance,  Taste  and  Smell. — ^A  well-marked  scum,  or  pel- 
licle, develops  on  the  surface  of  boiled  milk.  This  may  begin  to 
develop  at  as  low  a  temperature  as  122°  F.  (50°  C.)  (Pfaundler  and 
Schlossmann).^  This  is  due  to  the  disassociation  of  the  casein 
compounds  as  the  result  of  drying.    Its  composition  is: 

Fatty  matter 45.42% 

Casein  and  albuminoid 50 .  86% 

Ash 3.72%  (Rosenau) 

Changes  in  the  taste  and  smell  may  develop  at  as  low  a  tem- 
perature as  158°  F.  (70°  C.)  (Sommerfeld),^  but  are  usually  not 
marked  unless  the  milk  is  brought  nearly  to  the  boiling  point. 
Prolonged  boiling  changes  the  color  toward  brown,  the  amoimt  of 
change  depending  on  the  duration  of  the  boiling.    The  change  in 

^  Kaundler  and  Schlossmann:  The  Diseases  of  Children,  1908,  i,  303. 

*  Sommerfeld:  Handbuch  der  Milchkunde,  J.  F.  Bergman,  Wiesbaiden,  1909. 

179 


180  COMPOSITION  OF  BOILED  MILK 

color  is  due  to  the  caramelization  of  the  sugar.  Heating  at  150"  F. 
(65°  C),  or  over,  for  half  an  hour,  materially  delays  or  entirely 
prevents  the  rising  of  cream.  This  is  because  the  normal  agglutina- 
tion of  the  fat  droplets  is  broken  down  and  they  are  more  homoge- 
neously distributed  throughout  the  fluid  (Rosenau).^ 

Composition. — When  milk  is  boiled  there  is  a  partial  fixation 
of  the  calcium  salts,  which  are  probably  precipitated  in  the  form 
of  tricalcium  phosphate  (Kastle  and  Roberts).^  There  is  also 
a  precipitation  of  the  magnesium  salts  (Rosenau).^  There  is  a 
diminution  in  the  amount  of  organic  and  an  increase  in  that  of 
inorganic  phosphorus  (Rosenau).^  About  one-third  of  the  citric 
acid  is  precipitated  in  the  form  of  tricalcium  citrate  (Pfaundler  and 
Schlossmann.^  About  90%  of  the  carbon  dioxid  and  50%  of  the 
oxygen  and  nitrogen  are  also  driven  off  (Pfaundler  and  Schloss- 
mann).^ There  is  also  a  certain  amount  of  decomposition  of  the 
compounds  of  casein  into  casein  and  its  base.  The  casein  is  ren- 
dered less  easy  of  coagulation  by  rennin  and  is  more  slowly  and 
imperfectly  acted  on  by  pepsin  and  pancreatin  (Rosenau).^  It  is 
difficult  to  understand  why  this  is  so,  because  the  precipitation  of 
the  soluble  albumins,  which  act  as  protective  colloids  (Alexander 
and  BuUowa),^  by  boiling,  should  make  the  coagulation  of  the 
casein  easier.  The  curd  produced  by  the  action  of  acids  (Pfaundler 
and  Schlossmann)  ^  and  rennin  (Rosenau)  ^  is,  moreover,  softer 
and  more  flocculent  than  that  in  raw  milk.  The  soluble  albumins 
are  entirely  precipitated  (Sommerfeld).^ 

There  are  no  available  data  as  to  the  temperature  at  which  the 
changes  which  take  place  in  boiled  milk  first  appear,  except  in  the 
case  of  the  soluble  albumins.  Sommerfeld  ^  quotes  Steward  to  the 
effect  that  heating  at  149°  F.  (65°  C.)  for  thirty  minutes  dimin- 
ishes them,  and  that  thirty  minutes  at  176°  F.  (80°  C.)  completely 
destroys  them.  Schlossmann  ^  found  a  slight  diminution  in  the 
solubility  of  the  albumins  at  158°  F.  (69°  C.)  and  Solomin  ^  states 
that  there  is  an  "apparent"  beginning  of  clotting  of  milk  albumin 
by  heating  at  140°  F.  (60°  C.)  for  fifteen  minutes,  but  he  is  not 

*  Rosenau:  Bulletin  56,  Hyg.  Lab.,  Pub.  Health  Service,  1909;  Circular  153, 
U.  S.  Dept.  Agric,  Bureau  of  Animal  Industry,  1910. 

=!  Kastle  and  Roberts:  Bulletin  56,  Hyg.  Lab.,  Pub.  Health  Service,  1909. 
'  Rosenau:  Bulletin  56,  Hyg.  Lab.,  Pub.  Health  Service,  1909;  Circular  153, 
U.  S.  Dept.  Agric,  Bureau  of  Animal  Industry,  1910. 

*  Pfaundler  and  Schlossmann:  The  Diseases  of  Children,  1908,  i,  303. 
5  Alexander  and  Bullowa:  Arch.  Pediat.,  1910,  xxvii,  18. 

'  Sommerfeld:  Handbuch  der  Milchkunde,  J.  F.  Bergman,  Wiesbaden,  1909. 
'Schlossmann:  Ztschr.  f.  physiol.  Chem.,  1896-7,  xxii,  197. 
"Solomin:  Arch.  f.  Hyg.,  1897,  xxviii,  43. 


DESTRUCTION  OF  BACTERIA  181 

sure  whether  or  not  it  is  really  the  lactalbmmn  which  is  involved. 
It  is  not  far  wrong  to  conclude,  therefore,  with  Hippius,^  that  the 
heating  of  milk  at  149°  F.  (65°  C.)  for  thirty  minutes  causes  no 
noteworthy  changes  in  the  chemical  composition  of  the  milk. 

Ferments. — According  to  Hippius,^  the  proteolytic  ferment  of 
cow's  milk  is  unchanged  by  heating  for  one  hour  at  140°  F.  (60°  C.) 
or  for  one-half  hour  at  .149°  F.  (65°  C),  but  is  destroyed  by  boil- 
ing, while  the  oxidizing  ferment  is  unchanged  by  heating,  even 
for  several  hours,  at  from  140°  F.  (60°  C.)  to  149°  F.  (65°  C),  but  is 
destroyed  by  one  hour  at  169°  F.  (76°  C).  Kastle  and  Porch  ^ 
have  shown,  moreover,  that  the  peroxidases  are  somewhat  in- 
creased by  heating  at  140°  F.  (60°  C). 

Bactericidal  Action. — The  bactericidal  power  of  milk  is  still 
considerable  after  continued  exposure  to  temperatures  of  from 
140°  F.  (60°  C.)  to  149°  F.  (65°  C),  but  is  destroyed  by  boiUng 
(Hippius)  '  The  alexins  are  affected  in  the  same  way  (Von  Behr- 
ing).'' 

Precipitin  Reaction. — ^The  heating  of  milk,  even  for  one  hour 
at  248°  F.  (120°  C.)  in  the  autoclave,  does  not  diminish  the  precip- 
itin reaction  (Hippius).^ 

Bacteria  and  Their  Products. — It  has  been  proved  by  many  in- 
vestigators that  the  typhoid  bacillus,  the  diphtheria  bacillus,  the 
dysentery  bacillus  and  the  cholera  vibrio,  as  well  as  the  other 
pathogenic  non-spore-bearing  organisms  most  often  found  in  milk, 
are  destroyed  in  milk  by  heating  at  140°  F.  (60°  C.)  for  twenty 
minutes  (Rosenau)  ^  and  at  higher  temperatures  for  shorter  lengths 
of  time.  Butyric  acid  bacteria  are  destroyed  at  from  212°  F. 
to  216°  F.  (100°  C.  to  102.2°  C.)  for  from  one  to  two  mmutea 
(Sommerfeld).^  The  spores  of  the  peptonizing  bacteria  are  much 
more  resistant,  however,  some  of  them  withstanding  boiling  for 
one  hour  (Sommerfeld).* 

Since  the  investigations  of  Fliigge,^  in  1894,  who  found  spore- 
bearing  peptonizing  bacteria  developing  in  milk  heated  at  158°  F. 
(70°  C.)  for  thirty  minutes  and  forming  highly  toxic  substances 
therein,  it  has  been  very  generally  believed  that  the  destruction 

^  Hippius:  Jahrb.  f.  Kinderheilk.,  1905,  Ixi,  365. 

*  Kastle  and  Porch:  Jour.  Biol.  Chem.,  1908,  iv,  301. 
»  Hippius:  Jahrb.  f.  Kinderheilk.,  1905,  Ixi,  365. 

*  Von  Behring:  Therap.  d.  Gegenw.,  1904,  N.  F.,  vi,  1. 

'Rosenau:  Bulletin  66,  Hyg.  Lab.,  Pub.  Health  Service,  1909;  Circular 
153,  U.  S.  Dept.  Agric,  Bureau  of  Animal  Industry,  1910. 

*  Sommerfeld:  Handbuch  der  Milchkunde,  J.  F.  Bergman,  Wiesbaden, 
1909. 

^  Flugge:  Ztschr.  f.  Hyg.,  1894,  jcvii,  272. 


182  DESTRUCTION  OF  BACTERIA 

of  the  lactic  acid  bacteria  by  pasteurization  resulted  in  the  un- 
hindered growth  of  undesirable,  proteolytic  bacteria,  which  pro- 
duced toxins  and  other  poisonous  products,  and  that  pasteurized 
milk  putrefied  rather  than  soured.  It  has  also  been  supposed 
that  bacteria  multiply  more  rapidly  in  pasteurized  than  in  raw 
milk,  Ayers  and  Johnson  ^  recently  found,  however,  that  many 
acid-forming  bacteria  are  not  destroyed  below  168°  F.  (75.6°  C.) 
and  that,  in  consequence,  pasteurized  milk  turns  sour  in  the  same 
way  as  raw  milk,  although  the  process  is  somewhat  delayed.  They 
found  that  there  were  fewer  peptonizing  bacteria  in  pasteurized 
than  in  raw  milk  and  that  they  did  not  multiply  rapidly.  The 
numerical  relations  of  the  acid-forming  bacteria,  the  peptonizing 
(putrefactive)  bacteria  and  the  inert  bacteria  were  practically  the 
same  as  in  clean,  raw  milk,  and  the  acid  development  in  an  effi- 
ciently pasteurized  milk  was  about  the  same  as  in  clean,  raw  milk. 
They  also  found  that  the  rate  of  multipHcation  of  bacteria  de- 
pended on  the  number  of  bacteria  present  in  the  milk.  The  rapid- 
ity of  multiplication  was  the  sanie  in  pasteurized  as  in  raw  milk 
containing  the  same  number  of  bacteria  and  more  rapid  in  both 
than  in  dirty  milk. 

It  is  generally  believed  that  the  heating  of  milk,  even  to  boihng, 
has  no  effect  on  the  toxic  products  of  bacterial  growth  which  it 
may  contain.  This  belief  is  in  part  justified  and  in  part  unwar- 
ranted. The  true  bacterial  toxins  are  thermolabile,  many  of  them 
being  rendered  inert  at  140°  F.  (60°  C).  Bacterial  endotoxins  may 
be  very  resistant,  however,  that  of  the  B.  coli  communis  being,  for 
example,  imaffected  by  fifteen  minutes  at  272°  F.  (134°  C).  There 
is  no  doubt  that  the  spore-bearing  organisms  can  set  up  putrefac- 
tive and  proteolytic  changes  in  milk  and  produce  poisons  as  the 
result.  The  nature  of  these  poisons  is  not  known.  Their  connec- 
tion with  "milk  poisoning"  has  been  inferred,  not  demonstrated. 
'Moreover,  as  far  as  is  known,  the  true  bacterial  toxins  play  but 
little,  if  any,  r61e  in  milk  poisoning  (Rosenau).^ 

THE  EFFECTS  OF  THE  HEATING  OF  MILK  ON  ITS  DIGESTIBILITY  AND  ON 
ITS   VALUE   AS  A   FOOD   FOR   INFANTS 

Experiments  in  Artificial  Digestion. — The  evidence  derived 
from  artificial  digestion  experiments  as  to  the  comparative  di- 
gestibility of  boiled  or  sterilized  and  raw  milk  is  inconclusive;  there 

^  Ayers  and  Johnson:  Bulletin  126,  U.  S.  Dept.  Agric,  Bureau  of  Animal 
Industry. 

2  Rosenau:  Bulletin  56,  Hyg.  Lab.,  Pub.  Health  Service,  1909;  Circular  153, 
U.  S.  Dept.  Agric,  Bureau  of  Animal  Industry,  1910. 


DIGESTIBILITY  OF  HEATED  MILK  183 

is  little  or  none  as  to  that  of  pasteurized  and  raw  milk.  The 
casein  is  rendered  less  easy  of  coagulation  by  rennin,  but  the  curd 
produced  by  the  action  of  acids  (Pfaundler  and  Schlossmann)  ^ 
and  rennin  (Rosenau)  ^  is  softer  and  more  flocculent  than  that  in 
raw  milk.  De  Jager  ^  concluded  that  raw  milk  was  the  more 
easily  digested,  while  Fleischmann  ^  decided  that  steriUzed  milk 
was  more  easily  acted  on  by  the  digestive  ferments  than  raw  mill^ 
Jemma  ^  and  Michael  ^  found  that  sterilization  did  not  impair 
the  digestibility  of  milk. 

Animal  Experiments. — Almost  all  experiments  agree  in  show- 
ing that  all  animals  do  better  when  fed  on  the  raw  than  on  the 
cooked  milk  of  their  own  species.  Von  Briinning  ^  has  collected 
reports  of  experiments  of  feeding  animals  with  the  raw  and  cooked 
milk  of  another  animal.  The  results  were  the  same  in  all,  namely, 
that,  when  fed  on  the  milk  of  another  animal,  the  young  animals 
did  better  when  the  milk  was  cooked  than  when  it  was  raw. 
Raudnitz  ^  fed  dogs  on  raw  and  on  sterilized  milk  and  found 
that  the  fat  and  nitrogen  were  better  utilized  with  the  raw  than 
with  the  sterilized  milk.  Lane-Claypon  *  has  reviewed  the  Ut- 
erature  of  this  subject  very  carefully  and  done  considerable  ex- 
perimental work  herself.  She  concludes  from  her  own  work  that 
there  is  no  evidence  to  show  that,  in  the  case  of  calves,  boiled 
cow's  milk  is  inferior  to  raw  cow's  milk  and  that,  if  young  ani- 
mals are  fed  upon  the  milk  of  a  suitable  foreign  species,  they 
appear  to  thrive  somewhat  better  if  the  milk  is  given  boiled  than 
raw: 

Experiments  on  Babies. — Lane-Claypon  *  has  recently  simimed 
up  the  work  which  has  been  done  in  feeding  babies  on  raw  and 
cooked  human  milk  and  arrives  at  the  conclusion  that  the  data 
available  are  insufficient  to  warrant  any  definite  decision  as  to  the 
comparative  nutritive  value  of  raw  and  boiled  human  milk  for 
babies.  There  is  no  doubt,  however,  that  many  babies  thrive  well 
on  boiled  human  milk. 

Very  few  metabolism  experiments  have  been  done  in  babies  as 

*  Pfaundler  and  Schlossmann:  The  Diseases  of  Children,  1908,  i,  303. 

*  De  Jager:  Centralbl.  f.  d.  med.  Wissensch.,  1896,  xxxiv,  145. 

'  Fleischmann:  Quoted  by  Doane  and  Price,  Bulletin  77  of  the  Maryland 
Agricultural  Experiment  Station,  1901. 

*  Jemma:  Dietet.  and  Hyg.  Gaz.,  1900,  xvi,  83. 
6  Michael:  Hyg.  Rundschau,  1899,  ix,  200. 

*  Von  Briinning:  Quoted  by  Finkelstein.    See  note  8. 
'Raundnitz:  Ztschr.  f.  physiol.  Chem.,  1890,  xiv,  1. 

*  Lane-Claypon:  Report  to  Local  Government  Board,  EIngland,  N.  S. 
No.  63. 


184  DIGESTIBILITY  OF  HEATED  MILK 

to  the  relative  utilization  of  raw  and  cooked  cow's  milk  and  these 
are  incomplete  and  fragmentary.  They  show,  however,  little  differ- 
ence in  the  results  with  the  two  foods.  Miiller  and  Cronheim  ^ 
found  that  the  calcium  was  less  well  utilized  when  the  milk  was 
cooked,  but  Finkelstein  ^  says  that  their  methods  are  open  to 
criticism.  Krasnogorsky,'  on  the  other  hand,  states  that  the  iron 
is  better  utilized  from  cooked  than  from  raw  milk. 

It  has  been  generally  believed  in  this  country  until  very  recently 
that  babies  fed  continuously  on  cooked  milk  do  not  thrive  so  well 
as  those  fed  on  raw  milk  and  that  the  cooking  of  milk  predisposes 
to  the  development  of  the  diseases  of  nutrition,  while  physicians  in 
Europe  have  believed  that  babies  thrive  as  well,  or  perhaps  better, 
on  cooked  than  on  raw  milk.  There  is,  however,  relatively  little 
evidence  on  either  side.  Finkelstein  ^  studied  sixty  well  and 
fifty-three  sick  babies  and  concluded  that  there  was  no  evident 
difference  in  the  results  with  raw  and  with  cooked  milk  and  that 
neither  the  gain  of  the  healthy  nor  the  healing  of  the  sick  was 
visibly  aided  by  raw  milk.  He  quotes  Czerny  as  having  obtained 
the  same  results  and  states  on  the  authority  of  an  oral  communica- 
tion that  the  experiment  of  feeding  raw  and  cooked  milk  to  a  large 
series  of  babies  had  been  tried  for  three  years  at  the  Waisenhaus  in 
Stockholm  and  that  no  difference  in  the  results  from  the  two  meth- 
ods had  been  noted.  Variot  ^  states  that  during  the  twelve  years 
ending  in  1904  more  than  3000  infants  were  fed  at  the  dispensary 
of  the  gmdte  de  lait  of  Belleville  with  milk  heated  at  226°  F.  (108" 
C.)  and  that  rachitis  did  not  develop  in  any,  but  that  anaemia  was 
not  uncommon.  Scurvy  is  not  mentioned.  Carel  ^  states  that  of 
210  infants  belonging  to  the  laboring  class  of  Paris  fed  on  raw  milk, 
31.8%  developed  rickets,  while  of  373  infants  of  the  same  class  fed 
on  cooked  milk  only  15%  developed  rickets  and  none  scurvy. 
Sill  ^  of  New  York  reports,  on  the  other  hand,  that  he  found  signs 
of  rickets  or  scurvy  in  97%  of  179  consecutive  cases  of  infants  fed 
on  pasteurized  or  sterilized  milk.  The  statistics  of  the  French 
observers  are  open  to  considerable  doubt,  however,  because,  unless 
the  French  infants  of  the  hospital  class  are  very  different  from  the 
American,  80%  of  them  show  signs  of  rickets,  no  matter  on  what 
they  are  fed,  while  scurvy  was  not  sufficiently  well  known  in 

^  Miiller  and  Cronheim:  Therap.  Monatsh.,  1903,  xvii,  340. 

2  Finkelstein:  Therap.  Monatsh.,  1907,  xxi,  508. 

'  Krasnogorsky:  Jahrb.  f.  Kinderheilk.,  1906,  Ixiv,  651. 

*  Finkelstein:  Th«>rap.  Monatsh.,  1907,  xxi,  508. 

*  Variot:  Compt.  rend.  Acad.  d.  Sc,  1904,  cxxxix,  1002. 
«  Carel:  Le  lait  sterilis6,  Thdse  de  Paris,  1902-3. 

^  SiU:  Med.  Rec,  New  York,  1902,  Ixii,  1016. 


SCURVY  AND  HEATED  MILK        185 

France  at  that  time  to  be  recognized  unless  of  a  most  extreme  type. 
Lane-Claypon  ^  has  recently  studied  a  series  of  babies,  part  of- 
whom  were  fed  on  breast-milk  and  part  on  boiled  cow's  milk,  at 
the  Municipal  Infant  Consultation  in  the  Naunyn  Strasse  in  Ber- 
lin. She  found  that  the  deficit  in  weight  in  the  babies  fed  on 
boiled  cow's  milk  below  those  fed  upon  the  breast  was  not  as 
much  as  10%  at  any  period.  She  also  sums  up  the  literature  of  the 
subject  in  her  paper. 

It  is  very  difficult  to  determine  what  influence  the  heating  of 
milk,  at  whatever  temperature,  has  on  the  development  of  rickets, 
because  the  exact  etiology  of  rickets  is  at  present  so  obscure.  It  is 
probable  that  heredity,  improper  hygienic  surroundings  and 
improper  food  all  play  a  part  in  its  production.  It  is  extremely 
difficult  to  know  in  an  individual  case  which  is  the  most  important 
element  and  almost  impossible  to  determine  it  in  large  series  of 
cases.  Our  present  statistics  as  to  the  relative  frequency  of  rachi- 
tis in  those  fed  on  heated  and  those  fed  on  raw  milk  are  not  ac- 
curate enough  to  form  the  basis  of  any  definite  conclusions  on  this 
point,  because  they  do  not  give  any  accurate  data  as  to  the  other 
possible  etiologic  conditions. 

The  evidence  to  prove  that  the  heating  of  milk  produces  scurvy 
is  stronger  than  in  the  case  of  rickets,  but  not  at  all  conclusive, 
this  evidence  being  the  fact  that  all  large  series  of  cases  of  scurvy 
show  that  a  considerable  proportion  of  the  patients  were  fed  on 
heated  milk,  more  of  them,  however,  on  steriUzed,  boiled  or 
scalded,  than  on  pasteurized  milk.  It  is  impossible  to  prove, 
however,  that  it  was  the  heating  of  the  milk  and  not  the  composi- 
tion of  the  food  which  caused  the  scurvy  in  these  babies.  It  is 
evident  that  when  an  individual  baby  is  fed  on  a  heated,  modified 
milk  it  is  impossible  to  know,  if  scurvy  develops,  whether  it  is  due 
in  the  special  case  to  the  heating  or  to  the  composition  of  the  milk. 
It  can  be  only  a  matter  of  opinion.  A  decision  can  be  reached 
only  by  the  analysis  of  large  series  of  cases.  It  may  even  then  be 
difficult,  as  is  shown  by  the  fact  that  the  series  collected  by  the 
American  Pediatric  Society,  the  largest  single  series  on  record,  is 
quoted  both  for  and  against  the  etiologic  influence  of  the  heating 
of  milk  in  the  production  of  scurvy.  Further  evidence  against  the 
heating  of  milk  causing  scurvy  is  that  scurvy  sometimes  develops 
in  the  breast-fed  and  in  babies  fed  on  raw  milk.  Still  further 
evidence  are  Plantenza's  ^  observations  that,  although  scurvy 

^  Lane-Clajrpon:  Report  to  Local  Government  Board,  England,  N.  SL 
No.  63. 

2  Plantenza:  Arch.  f.  Kinderheilk.,  1912,  Iviii,  155. 


186  COOKING.  OF  MILK  ADVISABLE 

developed  more  frequently  in  babies  fed  on  heated  milk  which 
was  not  used  at  once  than  on  raw  milk,  it  did  not  develop  when 
fresh  milk  was  heated  and  used  at  once. 

It  has  been  asserted  that  the  cooking  of  milk  "devitalizes"  it 
and  thus  renders  it  a  less  suitable  food  for  infants.  It  is  pre- 
sumable that  what  is  meant  by  -'devitalization"  is  the  destruction 
of  the  ferments.  The  point  at  which  this  occurs  has  already  been 
given,  showing  that  they  are  not  injured  at  temperatures  below 
150°  F.  (65°  C).  There  is  no  proof,  however,  that  the  ferments  of 
milk  play  any  part  in  the  digestion  and  utilization  of  the  milk,  the 
only  apparent  foundation  for  the  belief  that  they  do  being  a  state- 
ment of  Marfan  ^  in  1901  that  "it  is  probable  that  the  milk  fer- 
ments act  as  stimulators  and  regulators  of  nutrition,  and  that  they 
are  identical  in  function  with  the  ferments  elaborated  by  the 
various  tissues  and  are  intended  to  compensate  for  the  deficiency 
of  the  internal  secretions  of  the  new-born."  This  statement  is 
founded  entirely  on  analogies  and  hypotheses  and  not  on  experi- 
ments or  facts. 

Cooking  of  Milk  Advised  as  a  Routine  Measure. — The  boiling 
and  proper  pasteurization  of  milk  destroys  the  ordinary  non-spore- 
bearing  pathogenic  microorganisms.  The  bacterial  growth  in 
pasteurized  milk  is  the  same  as  in  clean,  raw  milk.  The  evidence 
at  present  available  is  insuflicient  to  show  whether  cooked  milk 
is  more  or  less  digestible  than  raw  milk,  whether  babies  thrive  on  it 
as  well  as  on  raw  milk  and  whether  or  not  it  predisposes  to  the 
development  of  the  diseases  of  nutrition.  Granting  that  the  cook- 
ing of  milk  does  make  it  somewhat  less  digestible  and  that  its 
continued  use  does  predispose  to  the  development  of  the  diseases 
of  nutrition,  it  is  evident,  nevertheless,  that  the  disturbances 
which  it  causes  are  slight  and  insignificant  in  comparison  with  the 
diseases  caused  by  milk  contaminated  with  bacteria.  All  milk, 
except  the  cleanest,  should,  therefore,  be  cooked  before  being  used 
as  a  food  for  infants. 

Pasteurization. — ^The  higher  the  temperature  at  which  milk  is 
heated,  the  greater  are  the  changes  in  its  composition.  While  it  is 
somewhat  problematical  how  much  influence  these  changes  have 
on  the  development  and  well-being  of  the  infant,  it  is  the  part  of 
wisdom  to  avoid  them  as  far  as  is  consistent  with  the  attainment 
of  the  object  of  cooking  milk,  that  is,  the  destruction  of  pathogenic 
microorganisms.  Pasteurization  is  therefore  preferable  to  boiling. 
The  temperature  of  the  pasteurization  should  be,  moreover,  as 
low  as  is  possible.  Pasteurization  at  140°  F.  (60°  C.)  for  twenty 
»  Marfan:  Presse  M^.,  1901,  ix,  13. 


PASTEURIZATION  187 

minutes  is  efficient ;  lower  temperatures  are  not.  This  temperature 
and  time  are,  therefore,  the  ideal  ones.  At  this  temperature  there 
is  no  change  in  the  taste,  odor  or  color  of  the  milk,  no  noteworthy 
changes  in  the  chemical  composition  are  produced,  the  ferments 
and  bactericidal  action  are  unaffected  and  bacterial  toxins  and 
non-spore-bearing  microorganisms  are  destroyed. 

There  are  three  methods  of  commercial  pasteurization  in  com- 
mon use:  the  flash  method,  the  holding  method  and  pasteuriza- 
tion in  the  bottle.  The  flash  method  consists  in  momentarily 
heating  the  milk  to  a  temperature  of  approximately  170°  F.  (76.7** 
C.)  by  allowing  it  to  flow  in  a  film  over  heated  metal  pipes  or  coils 
and  then  at  once  chilling  it.  The  holding  method  consists  in 
heating  the  milk  to  between  140°  F.  (60°  C.)  and  155°  F.  (68°  C.) 
and  then  placing  the  milk  in  a  receptable  where  it  is  held  at  approx- 
imately this  temperature  for  from  twenty  minutes  to  an  hour. 
The  flash  method  has  been  repeatedly  shown  to  be  unreliable  and 
should  not  be  employed.  The  holding  method  is  not  so  satisfactory 
as  would  at  first  appear,  because,  while  the  destruction  of  the 
bacteria  in  a  small  quantity  of  milk  by  heating  it  at  140°  F.  (60°  C.) 
for  twenty  minutes  is  simple  enough,  it  is  very  difficult  to  heat  a 
large  volume  of  milk  to  a  definite  temperature  and  hold  it  at  that 
temperature  for  a  given  period  of  time.  Schorer  and  Rosenau  ^ 
have  shown  that  under  ordinary  commercial  conditions  the  tem- 
peratures expected  were  not  attained.  In  their  four  experiments, 
two  planned  for  140°  F.  (60°  C.)  and  two  for  145°  F.  (62.7°  C), 
from  99.4%  to  99%  of  the  bacteria  were,  nevertheless,  destroyed. 
A  certain  number  of  pathogenic  microorganisms,  however,  sur- 
vived. They  conclude,  therefore,  that  in  order  to  be  safe,  pasteur- 
ization under  commercial  conditions  should  be  at  145°  F.  (62.7°  C.) 
for  from  thirty  to  forty-five  minutes.  Schorer  ^  further  concludes 
that  the  safest  method  for  pasteurization  is  in  the  sealed  bottle, 
allowing  at  least  thirty  minutes  for  heating  to  the  temperature 
of  pasteurization  and  then  pasteurizing  at  145°  F.  (62.7°  C.)  for 
thirty  minutes.  He  also  wisely  advises  that  all  conmaercial  pasteur- 
ization shall  be  carried  out  under  official  supervision. 

It  must  never  be  forgotten  that  the  pasteurization  of  milk  does 
not  do  away  with  the  necessity  of  taking  care  of  it  and  keeping  it 
cold.  It  is  just  as  important  to  keep  pasteurized  milk  cold  as  it  is 
to  keep  raw  milk  cold,  because  pasteurization  simple  diminishes 
the  number  of  microorganisms.    It  does  not  destroy  them  entirely. 

While  it  is  easier  to  approach  laboratory  methods  in  the  home 

*  Schorer  and  Rosenau:  Jour.  Med.  Res.,  1912,  xxvi,  127. 
« Schorer:  Am.  Jour.  Dis.  Child.,  1912,  iii,  226. 


188  PASTEURIZATION 

than  under  commercial  conditions,  it  is  wiser  to  adopt  145°  F. 
(62,7°  C.)  for  thirty  minutes  as  the  standard  instead  of  140°  F. 
(60°  C.)  for  twenty  minutes,  in  order  to  be  sure  that  the  pasteur- 
ization is  efficient.  The  changes  produced  in  the  milk  at  this 
temperature  and  time  are  little,  if  any,  greater  than  at  the  lower 
temperature  and  shorter  tune. 

It  is  not  necessary  to  have  any  special  apparatus  for  the  pasteur- 
ization of  milk  in  the  home,  as  any  dish  of  sufficient  size  and  depth 
will  do.  Each  feeding  should  be  placed  in  a  separate,  clean,  boiled 
bottle.  The  bottle  should  then  be  tightly  stoppered  with  non- 
absorbent  cotton  and  placed  in  a  pail  or  dish  of  cold  water,  the 
water  in  the  dish  being  at  the  level  of  the  milk  in  the  bottle.  The 
dish  should  then  be  placed  on  the  stove  and  heated  until  the  ther- 
mometer, suspended  in  the  water,  reaches  145°  F.  (62.7°  C).  The 
dish  and  its  contents  should  then  be  taken  off  the  stove  and  covered 
with  a  blanket.  It  should  be  allowed  to  stand  for  thirty  min- 
utes. The  bottles  should  then  be  taken  out,  cooled  quickly, 
preferably  in  running  water,  and  kept  in  a  cold  place  until  used. 

There  are  several  pasteurizers  on  the  market,  designed  for  home 
use,  which  are  more  convenient,  although  no  more  efficient.  That 
sold  by  the  Walker-Gordon  Laboratory  is  a  good  one.  Another, 
designed  by  Dr.  R.  G.  Freeman  of  New  York,  although  working 
on  a  little  different  principle,  is  very  satisfactory. 

Sterilization  by  electricity  is  carried  on  in  bulk  in  the  plant 
of  the  Liverpool  Corporation  Milk  Depot.  All  bacteria  of  the 
bacillus  coli  group,  those  bacteria  which  sour  milk,  probably  the 
streptococci  and  bacillus  of  tuberculosis  are  said  to  be  destroyed 
by  the  use  of  2.2  amperes  at  3900  to  4200  volts  for  two  to  three 
seconds.    The  temperature  reached  by  the  milk  is  64°  F.^ 

»Beattie:  Jour.  State  Med.  1916,  xxiv   97. 


CHAPTER  XVI 
CERTIFIED  MILK 

Certified  milk  is  the  product  of  dairies  operated  in  accordance 
with  accepted  rules  and  regulations  formulated  by  authorized 
medical  milk  commissions  to  insure  its  purity  and  adaptability 
for  infants  and  invalids.  The  methods  and  standards  for  the 
production  and  distribution  of  certified  milk  adopted  by  the  Amer- 
ican Association  of  Medical  Milk  Commissions,  May  1,  1912,  are 
in  brief  as  follows: 

The  surroundings  of  all  buildings  shall  be  kept  clean  and  free 
from  accumulations  of  dirt  of  all  sorts,  and  the  stable  yards  shall  be 
well  drained.  The  pastures  shall  be  free  from  marshes,  stagnant 
pools  or  streams  which  may  be  contaminated.  The  buildings  shall 
be  so  located  as  to  afford  proper  shelter  and  drainage  and  relative 
freedom  from  dust.  The  stables  shall  be  so  constructed  as  to 
facihtate  the  prompt  and  easy  removal  of  waste  products.  The 
floors  shall  be  of  non-absorbent  material  and  the  gutters  of  cement. 
All  interior  construction  shall  be  smooth  and  tight.  The  drinking 
and  feed  troughs  shall  be  cleaned  daily.  The  stanchions  shall  be 
provided  with  throat  latches.  The  stables  must  be  provided  with 
adequate  ventilation,  each  cow  having  at  least  600  cubic  feet  of  air 
space,  with  2  ft  square  of  window  area  for  each  600  cubic  feet  of 
air  space.  Flies,  vermin  and  other  animals  shall  be  excluded  from 
the  buildings.  The  bedding  must  be  clean  and  dry.  The  soiled 
bedding  and  manure  shall  be  removed  at  least  twice  daily.  Man- 
ure shall  not  be  even  temporarily  stored  within  300  feet  of  the 
barn  or  dairy  building.  Cleaning  of  the  bam  shall  be  done  at 
least  an  hour  before  milking  time.  The  cows  shall  be  groomed 
daily,  and  the  hairs  about  the  udder  and  tail  clipped  short.  The 
udders  and  teats  shall  be  cleaned,  washed  with  a  cloth  and  water 
and  wiped  dry  with  another  clean  sterilized  cloth,  before  milking. 
Food-stuffs  shall  be  brought  into  the  bam  only  immediately  be- 
fore the  feeding  hour,  which  shall  follow  the  milking.  The  food 
shall  be  suitable  and  well  balanced.  The  cows  must  have  at  least 
two  hours  out  of  door  exercise  daily  in  suitable  weather.  The 
hands  of  the  milkers  shall  be  washed  throughly  and  dried  before 
beginning  milking  and  before  the  milking  of  each  cow.    Clean 

189 


190  CERTIFIED  MILK 

outside  clothes  and  a  cap  shall  be  worn  during  milking,  these  to 
be  washed  or  sterilized  each  day.  The  fore-milk  shall  be  rejected. 
The  milk  of  all  cows  shall  be  excluded  for  a  period  of  forty-five 
days  before  and  seven  days  after  parturition.  The  milk  shall  be 
taken  immediately  to  a  clean  room  and  emptied  through  strainers 
of  cheesecloth  or  absorbent  cotton  into  a  can. 

The  dairy  building  shall  be  located  at  a  suitable  distance  from 
the  stable  and  dwelling  ajid  there  shall  be  no  hogpen,  privy  or 
manure  pile  at  a  higher  level  or  within  300  feet  of  it.  The  dairy 
building  shall  be  kept  clean  and  shall  not  be  used  for  purposes 
other  than  the  handling  and  storing  of  milk  and  milk  utensils. 
It  shall  be  well  lighted,  screened  and  drained. 

The  temperature  of  the  milk  shall  be  immediately  reduced  to 
45°  F.  and  maintained  at  a  temperature  between  35°  F.  and  45°  F. 
until  delivery  to  the  consumer.  The  bottles  shall  be  properly 
sealed,  the  seal  to  include  a  sterile  hood  which  completely  covers 
the  lip  of  the  bottle.  The  bottles  shall  be  properly  cleaned  and 
sterilized.  The  milk  pails  shall  be  properly  made  and  preferably 
have  an  elUptical  opening  5  by  7  inches  in  diameter.  The  water 
supply  shall  be  free  from  contamination.  Proper  toilet  facilities 
shall  be  provided  for  the  milkers  outside  the  stable  and  milk  house. 

The  milk  packages  must  be  kept  free  from  dust  and  dirt  during 
transportation.  No  bottles  shall  be  collected  from  houses  in  which 
there  is  a  communicable  disease.  All  certified  milk  shall  reach  the 
consumer  within  thirty  hours  after  milking. 

The  herd  shall  be  free  from  tuberculosis,  as  shown  by  the  proper 
application  of  the  tuberculin  test  by  the  veterinarian  of  the  com- 
mission. The  test  shall  be  applied  at  least  annually.  All  cows 
shall  be  properly  registered.  Cows  sick  with  other  diseases  than 
tuberculosis  shall  be  isolated  and  their  milk  destroyed  until  the 
cows  are  restored  to  the  herd  by  the  veterinarian. 

Certified  milk  shall  contain  less  than  10,000  bacteria  per  cubic 
centimeter  when  deUvered.  Bacterial  counts  shall  be  made  at 
least  once  a  week. 

The  fat  standard  for  certified  milk  shall  be  4%,  with  a  permis- 
sible range  of  variation  of  from  3.5%  to  4.5%.  Higher  fat  per- 
centages for  milk  or  cream  may,  however,  be  certified.  The  fat 
content  shall  be  determined  at  least  once  a  month. 

The  protein  standard  shall  be  3.50%,  with  a  permissible  range 
of  variation  of  from  3%  to  4%.  The  milk  shall  be  free  from  adul- 
teration and  coloring  matter,  and  preservatives  shall  not  be  added 
thereto.  The  milk  shall  not  be  subjected  to  heat  unless  especially 
directed  by  the  commission  to  meet  emergencies.     The  specific 


CERTIFIED  MILK  191 

gravity  shall  range  from  1.029  to  1.034.  It  shall  be  determined 
at  least  once  a  month. 

No  person  shall  be  employed  in  the  production  or  handling  of 
milk  until  he  has  been  found  healthy  by  the  attending  physician. 
No  person  shall  be  employed  who  has  been  recently  associated  with 
children  sick  with  contagious  diseases.  Suitable  dormitories  and 
bathing  facilities  shall  be  provided  for  the  employees  and  they 
shall  be  required  to  use  them.  If  a  contagious  disease  develops 
among  the  employees,  the  employees  shall  be  quarantined,  the 
premises  fumigated  and  the  milk  pasteurized  as  long  as  the  com- 
mission thinks  necessary.  The  commission  shall  have  power  to  act 
as  its  judgment  dictates  when  contagious  diseases  are  present. 

It  is  possible  to  produce  a  reasonably  clean  milk  without  ful- 
filling all  the  requirements  of  the  American  Association  of  Medical 
Milk  Commissions  for  the  production  of  certified  milk.  It  is 
possible  to  do  this,  moreover,  without  increasing  materially  the 
cost  of  the  production  of  the  milk.  The  milkers  and  those  who 
handle  the  milk  must,  of  course,  be  clean.  So  also  must  be  the 
utensils  which  are  used.  The  bams  can  easily  be  so  arranged  as  to 
be  reasonably  free  from  dust  and  dirt.  Experience  has  shown  that 
the  contamination  of  the  milk  is  much  less  when  the  cows  are  milked 
out  of  doors  than  when  they  are  milked  indoors.  If  the  cows  are 
milked  indoors  certain  precautions  should  be  taken  to  avoid  filling 
the  air  with  dust.  No  dry  feed  should  be  given  at  or  just  before 
the  time  of  the  milking  and  the  floors  should  not  be  scraped  or 
cleaned  just  before  milking.  The  cows  should  not  be  dry  brushed 
before  milking.  The  flanks  and  udders  may  be  wiped  instead  of 
washed  before  the  milking.  This  is  nearly  as  effectual  and  much 
less  expensive.  A  covered  milk  pail  should  always  be  used  as  it 
diminishes  the  contamination  at  least  50%. 


CHAPTER  XVII 
GENERAL  PRINCIPLES  OF  ARTIFICIAL  FEEDING 

In  approaching  the  subject  of  artificial  feeding  it  must  be  remem- 
bered that  there  are  only  a  few  food  elements.  A  baby's  food  may 
contain  all  of  these  elements,  it  must  contain  some  of  them,  it 
cannot  contain  any  other  elements.  These  food  elements  are  fat, 
carbohydrates,  protein  and  salts.  The  carbohydrates  comprise 
the  sugars  and  starches. 

It  must  also  be  remembered  that  a  baby,  in  order  to  thrive  and 
gain,  must  have  a  sufficient  amount  of  food.  The  amount  of  food 
is  not  calculated,  however,  in  ounces  or  pints  of  food,  but  in  food 
values,  or  calories.  A  baby  must  receive  a  sufficient  number  of 
calories  in  proportion  to  its  body  weight.  Otherwise,  it  cannot 
gain.  It  is  not  sufficient,  however,  for  a  food  to  contain  a  sufficient 
number  of  calories;  it  must  also  contain  a  sufficient  amount  of 
protein  to  cover  the  nitrogenous  needs  of  the  baby.  A  baby  will 
eventually  die  while  taking  a  food  high  in  calories  but  too  low  in 
protein. 

It  must  further  be  remembered  that  a  food  may  contain  a 
sufficient  number  of  calories  and  a  sufficient  amount  of  protein  to 
cover  the  caloric  and  protein  needs  of  the  baby  and  yet  not  be  a 
suitable  food  for  any  baby,  or,  if  suitable  for  one  baby,  not  for 
another.  It  is  absolutely  necessary  to  fit  the  food  to  the  digestive 
capacity  of  the  individual  infant.  Otherwise  it  will  cause  disturb- 
ance of  the  digestion  and  the  baby  will  not  thrive. 

These  fundamental  principles  must  always  be  borne  in  mind  in 
feeding  babies  artificially.  If  a  single  one  of  them  is  forgotten,  the 
results  will  be  failure  rather  than  success. 

It  would  seem  at  first  glance  as  if  an  artificial  food,  which  con- 
tained the  same  food  elements  in  the  same  relative  proportions 
that  they  are  in  human  milk,  would  be  a  perfect  food  and  answer 
as  well  as  human  milk.  It  has  been  shown,  however,  that,  while 
some  babies  will  thrive  on  a  food  of  this  composition,  it  is  not 
suitable  for  all  babies  or  for  all  ages.  While  babies  thrive  through- 
out the  nursing  period  on  human  milk  of  imiform  strength,  they 
cannot  take  a  food  as  strong  as  this  in  the  early  weeks  and  months, 
and  need  a  stronger  food  in  the  latter  months.    It  is  a  fact,  more- 

192 


BREAST  MILK  NOT  IMITATED  193 

over,  that  no  artificial  food,  although  it  may  contain  the  same 
proportions  of  the  different  food  elements,  is  the  same  as  human 
milk.  It  is  impossible,  as  will  be  shown  later,  to  make  an  artificial 
food  in  any  way  which  is  identical  with  human  milk. 

The  composition  of  human  milk  does,  however,  teach  us  certain 
things  as  to  the  digestive  capacity  of  infants  and  as  to  the  general 
principles  to  be  followed  in  the  preparation  of  a  food  to  meet  this 
digestive  capacity.  Nature  provides  a  dilute  food  rich  in  fat  and 
carbohydrates  and  relatively  low  in  protein,  that  is,  rich  in  heat- 
producing  substances  and  relatively  low  in  tissue-building  sub- 
stances. It  seems  reasonable  to  suppose  that  this  type  of  food  is 
the  one  best  suited  for  the  infant's  digestive  power  and  metabolic 
processes.  Well  babies  should,  therefore,  be  given  dilute  foods 
which  contain  relatively  large  amounts  of  fat  and  carbohydrates 
and  relatively  small  amounts  of  protein.  The  object  in  giving 
babies  such  foods  is,  however,  not  to  imitate  the  composition  of 
breast-milk  but  to  follow  Nature's  indications  as  to  the  infant's 
digestive  capacity  and  metabolic  processes.  Well  babies,  as  al- 
ready stated,  on  the  whole  thrive  better  on  foods  of  this  char- 
acter than  on  any  others.  The  same  principles  cannot,  however, 
be  applied  to  the  feeding  of  sick  babies  or  to  that  of  a  certain 
number  of  well  babies.  When  a  baby  does  not  thrive  on  foods  of 
this  type,  they  must  be  discarded  at  once  and  the  composition  of 
the  food  regulated  to  fit  the  digestive  capacity  of  the  individual 
baby.  This  digestive  capacity  must  be  determined  by  a  careful 
study  of  the  symptoms  and  of  the  stools  in  the  individual  case. 
The  composition  of  the  food  must  then  be  varied  to  suit  the  in- 
dividual baby.  Success  in  the  artificial  feeding  of  infants  can 
never  be  attained  by  following  any  hard  and  fast  rules.  Every 
baby  is  a  problem  by  itself.  The  baby,  not  rules,  must  be  followed 
to  solve  this  problem. 

The  artificial  food  for  a  baby  is  best  prepared  from  the  milk  of 
some  animal  for  the  following  reasons:  The  milk  of  animals  con--j  .  i 
tains  the  same  food  elements  which  are  present  in  human  milkt  ('"^ 
It  does  not  contain  any  other  elements.  It  is  intended  for  the 
growth  and  development  of  a  young  animal.  No  other  food  has 
these  same  characteristics.  It  must  be  remembered,  however,  that 
the  milk  of  an  animal  is  fitted  to  the  digestive  capacity  and  in- 
tended for  the  growth  and  development  of  the  young  of  that 
animal  and  not  for  the  hiunan  infant.  It  is,  therefore,  not  entirely 
suitable  for  a  baby,  and,  while  some  babies  will  thrive  on  the  un- 
diluted milk  of  an  animal,  in  most  instances  it  has  to  be  modified 
in  some  way  to  be  suitable  for  a  baby. 


194  IDIOSYNCRASY  TO  COW'S  MILK 

The  milk  of  the  cow  is  the  one  most  suitable  for  the  preparation 
of  a  baby's  food.  The  millc  of  the  mare,  it  is  true,  resembles  more 
closely  in  its  composition  that  of  human  milk  than  does  cow's  milk. 
Its  use  as  a  food  for  babies  is,  however,  not  feasible,  because  of  its 
rarity  and  the  difficulty  in  obtaining  it.  The  milk  of  the  goat, 
which  is  claimed  by  some  authorities  to  be  better  than  cow's 
milk  as  a  food  for  babies,  is  very  much  like  cow's  milk  in  its  com- 
position. It  has  to  be  modified  to  fit  the  digestion  of  the  average 
baby  in  the  same  way  as  cow's  milk.  Cow's  milk  is  easy  to  obtain 
in  any  amount,  in  almost  any  place.  It  is  difficult  to  obtain  goat's 
milk  in  large  amounts,  and  then  only  in  a  few  places.  There  is, 
therefore,  no  reason  for  preferring  goat's  milk  to  cow's  milk.  The 
reasons  that  goat's  milk  has  been  considered  better  than  cow's 
milk  for  the  feeding  of  infants  are  probably  because  goat's  milk 
was  given  to  the  babies  when  it  was  fresh  and  cow's  milk  when 
it  was  old,  and  because  in  the  countries  where  goat's  milk  was  used 
most  freely  the  cows  were  tubercular  and  the  goats,  on  account 
of  their  resistance  to  infection  with  tuberculosis,  were  not.  At 
the  present  time  when  so  much  is  known  about  infant  feeding, 
these  reasons  are  not  appficable.  Pure  milk  can  now  be  obtained 
by  anyone  who  will  take  the  trouble  to  get  it,  and  anyone  who 
does  not  take  the  trouble  to  find  out  whether  the  milk  which  is 
given  to  a  baby  comes  from  tuberculin  tested  cows  or  not,  de- 
serves to  have  tuberculosis  develop  in  the  babies. 

Idiosyncrasy  to  Cow's  Milk. — It  is  often  said  that  certain 
babies  cannot  take  cow's  milk  in  any  form  and  that  they  must  be 
fed,  therefore,  in  some  other  way.  In  most  of  these  cases  the 
trouble  is  not  with  cow's  milk  but  with  the  way  in  which  it  has 
been  given.  Almost  all  of  these  babies  can  take  cow's  milk  per- 
fectly well  if  it  is  properly  modified  to  fit  their  individual  digestive 
capacities.  In  rare  instances,  however,  cow's  milk  does  cause 
serious  disturbances  in  whatever  form  it  is  given,  whether  as 
cream,  skimmed  milk,  whey  or  condensed  milk.  In  such  cases  even 
«,  very  small  amount  will  cause  trouble.  In  these  instances  the 
sjTnptoms  are  manifestations  of  anaphylaxis  to  the  protein  of  cow's 
milk.  If  a  skin  test  to  cow  casein  is  performed,  a  positive  re- 
action is  obtained  in  the  majority  of  instances.  Such  a  positive 
reaction  establishes  the  diagnosis  of  idiosyncracy  to  cow's  milk. 
There  is  often  a  family  history  of  anaphylaxis  to  some  foreign 
protein.  It  will  almost  always  be  found  that  these  babies  were 
given  cow's  milk  in  the  first  few  days  of  life  at  a  time  when  the 
intestines  were  in  an  abnormal  condition.  The  foreign  protein 
of  the  cow's  milk  was  probably  absorbed  at  that  time  and  pro- 


MODIFIED  MILK  196 

duced  the  sensitization.  In  a  few  instances  an  idiosyncracy  devel- 
ops in  later  infancy,  especially  when  the  cow's  milk  is  given  for  the 
first  time  at  intervals  of  ten  days  or  more,  thus  sensitizing  the 
infant  in  a  similar  manner  to  experimental  sensitization  in  animals. 
Such  babies  have  to  be  given  either  breast-milk  or  goat's  milk 
until  they  are  old  enough  to  take  other  foods  than  milk.  They 
may,  however,  be  desensitized  by  giving  them  minute  doses  of 
cow's  milk,  gradually  increasing  the  amount  until  immunity  is 
obtained.  This  procedure  as  a  rule  is  unnecessary  because  the 
idiosyncrasy  is  usually  outgrown  during  early  childhood. 

Modified  Milk. — The  composition  of  human  milk  and  cow's 
milk  has  already  been  given.    They  are  roughly  as  follows; 

TABLE  38 

Human  milk  Cow's  milk 

Fat 4.00%  4.00% 

Sugar 7.00%  4.75% 

Protein 1.50%  3.50% 

Salts 0.20%  0.70% 

Both  are  amphoteric  in  reaction  when  they  leave  the  breast. 
Cow's  milk  is  usually  acid  when  it  reaches  the  baby.  Human 
mUk  is  practically  sterile  as  the  baby  takes  it.  Cow's  milk,  even 
under  the  best  conditions,  is  far  from  sterile  when  the  baby  gets  it. 
The  emulsion  of  the  fat  is  much  finer  in  human  milk  than  in  cow's 
milk.  The  proportion  of  fatty  acids  is  much  higher  in  cow's  milk 
than  in  human  milk.  A  large  proportion  of  the  protein  in  human 
milk  is  in  the  form  of  whey  protein.  A  large  proportion  of  the 
protein  in  cow's  milk  is  in  the  form  of  casein.  Human  milk  is  not 
coagulated  by  commercial  rennin,  cow's  milk  is  coagulated.  Both 
are  coagulated  by  human  rennin.  The  enzymes  of  the  two  milks 
are  different  and  each  milk  has  a  specific  serum  reaction. 

It  is  evident,  therefore,  that  no  matter  how  cow's  milk  is  mod- 
ified, it  will  still  be  different  from  human  milk.  The  percentages 
of  the  different  food  elements  can  be  made  the  same.  The  differ- 
ence in  the  protein  can  be  corrected  by  the  use  of  whey.  The 
emulsion  and  the  composition  of  the  fat  will,  however,  always  be 
different.  The  ferments  can  never  be  made  the  same  and  the 
specific  serum  reaction  cannot  be  changed.  It  is  also  evident  that 
cow's  milk  must  be  modified  in  some  way  in  order  that  the  different 
food  elements  may  be  in  the  same  relations  in  the  food  that  they 
are  in  human  milk. 

Pure  Milk. — ^The  milk  from  which  a  baby's  food  is  prepared 
must  be  pure.    It  is  impossible  to  make  a  proper  food  for  a  baby 


196  BREEDS  OF  COWS 

from  impure  and  dirty  milk,  no  matter  how  much  it  is  modified  or 
how  much  care  is  taken  in  its  preparation.  The  requisites  of  a 
pure  milk  have  already  been  described. 

Breeds  of  Cows. — It  also  makes  a  difference  from  what  breed 
of  cows  the  milk  comes.  The  milk  of  Ayreshires  and  Holsteins  is 
much  more  suitable  than  that  of  Jerseys  and  Guernseys,  because 
of  the  lesser  fat  content,  the  finer  division  of  the  fat  and  the  lower 
proportion  of  volatile  fatty  acids.  The  milk  of  the  former  breeds 
should,  therefore,  be  always  employed,  if  possible.  Some  babies 
can  take  Jersey  milk  without  being  disturbed,  other  babies  cannot.. 
It  will  be  found  in  many  instances  that  babies  can  take  the  same 
amount  of  fat  in  mixtures  made  from  the  milk  of  Holstein  and 
Ayreshire  cows  without  derangement  of  digestion,  while  there  is 
serious  disturbance  when  the  milk  comes  from  Jerseys  or  Guern- 
seys. 

Mixed  Milk  versus  the  Milk  of  One  Cow. — It  is  far  better,  other 
things  being  equal,  to  use  the  mixed  milk  of  a  herd  in  preparing  a 
baby's  food  than  the  milk  of  one  cow,  because  if  the  milk  comes 
from  one  cow  and  the  cow  is  ill  in  any  way,  the  baby  is  almost 
certain  to  be  disturbed,  whereas  if  one  or  two  cows  in  a  herd  are 
ill,  the  milk  from  these  cows  will  be  so  diluted  that  the  baby  will 
probably  not  notice  it.  On  the  other  hand,  it  is,  or  should  be, 
self-evident  that  the  milk  of  a  healthy  cow  properly  fed  and 
properly  cared  for,  taken  in  the  proper  way,  and  kept  under  proper 
conditions,  is  better  than  the  mixed  milk  of  a  herd  which  is  im- 
properly fed  and  whose  milk  is  not  carefully  obtained  or  carefully 
taken  care  of. 

GENERAL   PRINCIPLES   OF   THE   MODIFICATION   OF  MILK 

It  is  evident,  when  the  composition  of  human  milk  and  cow's 
milk  is  compared,  that,  while  the  percentage  of  fat  is  the  same  in 
the  two  milks,  the  percentage  of  sugar  is  higher  and  that  of  the 
protein  lower  in  human  than  in  cow's  milk.  It  is  necessary,  in 
order  to  have  foods  prepared  from  cow's  milk  correspond  in  the 
general  relations  of  the  fat,  sugar  and  protein  to  each  other  to 
those  in  human  milk  and,  therefore,  to  meet  the  indications  for  a 
food  suitable  for  the  average  well  baby,  to  modify  these  relations  in 
some  way.  Simple  dilution  of  cow's  milk  does  not  change  these 
relations  at  all.  Simple  dilutions  of  whole  milk  do  not,  therefore, 
provide  a  suitable  food  for  the  average  well  baby. 

It  is  a  fact  that  when  milk  stands  the  fat  rises  to  the  top,  while 
the  sugar  and  protein  remain  approximately  evenly  divided 
throughout  the  mixture.    This  fact  of  the  unequal  division  of  the 


PRINCIPLES  OF  MILK  MODIFICATION  197 

fat  axid  the  comparatively  equal  division  of  the  sugar  and  protein 
is  also  true  when  milk  is  separated  by  machinery.  The  cream 
contains  a  relatively  large  amount  of  fat  and  a  relatively  small 
amount  of  sugar  and  protein,  when  compared  with  whole  milk. 

Cream  is  technically  any  milk  which  contains  more  than  4%  of 
fat.   The  composition  of  different  creams  is  as  follows : 

TABLE  39 


Fat 

Sugar 

Protein 

10%  cream 

16%     "       

10% 
16% 

32% 

^A5% 
4.20% 
3.40% 

z. 2:770 

3.05% 

32%     "       

2.50% 

It  is  evident  that  when  cream  is  diluted  the  relation  between  the 
fat  and  the  protein  will  be  similar  to  that  in  human  milk.  For 
example,  a  mixture  of  one  part  of  16%  cream  with  three  parts  of 
water  will  contain  4%  of  fat  and  about  0.75%  of  protein,  while  a 
mLxture  of  one  part  of  10%  cream  with  three  parts  of  water  will 
contain  2.50%  of  fat  and  approximately  0.80%  of  protein.  It  is 
very  easy  to  raise  the  percentage  of  sugar,  in  order  to  get  a  rela- 
tively high  sugar  content,  by  the  addition  of  dry  milk  sugar.  The 
modification  of  cow's  milk  to  fulfill  the  indications  given  by  Nature 
as  to  the  average  infant's  digestive  capacity  consists  roughly, 
therefore,  in  the  dilution  of  cream  with  water  and  the  addition  of 
dry  milk  sugar. 

If  the  modifications  of  milk  prepared  on  these  general  principles 
do  not  fit  the  individual  baby,  it  is  easy  to  increase  the  percentage 
of  protein  in  relation  to  the  percentage  of  fat  by  the  addition  of 
skimmed  or  fat-free  milk,  which  contain  a  considerable  amont  of 
protein  and  very  httle  fat.  If  the  casein  is  not  easily  digested,  it  is 
easy  by  the  use  of  whey  in  the  mixture  to  replace  a  part  of  it  by 
whey  protein.  If  it  is  desired  to  give  a  baby  starch  in  its  food, 
starch  can  be  added  in  the  form  of  a  cereal  water.  If  it  is  desired, 
for  any  reason,  to  change  the  character  of  the  sugar,  another  sugar 
may  be  added  in  place  of  milk  sugar.  In  these  ways  all  possible 
modifications  of  cow's  milk  may  be  obtained  and  the  needs  of  the 
individual  baby  met. 

FEEDING   IN   PERCENTAGES 

The  most  satisfactory  way  of  determining  the  composition  of  an 
infant's  food  is  by  thinking  and  calculating  in  percentages  of  the 
different  elements  of  the  food.    Percentage  feeding,  so-called,  is  not 


198  FEEDING,  IN  PERCENTAGES 

a  method  of  feeding.  It  is  merely  a  method  of  calculation  and  a 
means  of  attaining  relative  accuracy  in  the  preparation  of  infants' 
foods.  It  neither  presupposes  nor  implies  anything  as  to  what 
should  be  in  the  food  or  why  it  should  be  there.  These  points  must 
be  determined  in  other  ways.  Accuracy  is  as  important  in  the 
calculation  and  writing  of  a  prescription  for  a  baby's  food  as  in  that 
for  a  medicine.  In  no  other  way  are  such  accurate  results  obtained 
as  by  the  percentage  method.  It  must  not  be  supposed,  however, 
that  the  mixtures,  when  prepared,  contain  exactly  the  percentages 
of  the  food  elements  which  they  are  calculated  to  contain.  This 
would  be  an  impossibihty,  because  the  cream,  milk  and  so  on  of 
which  they  are  made  are  not  constant  in  their  composition.  This 
is  especially  true  when  the  mixtures  are  prepared  at  home.  The 
percentages  are,  however,  approximately  correct  and  nearly  enough 
so  for  practical  purposes.  Fortunately  most  babies  do  not  notice 
slight  variations  in  the  composition  of  the  food.  In  fact,  the  varia- 
tions in  the  composition  of  a  mixture  from  day  to  day  are  probably 
less  than  the  daily  variations  in  the  composition  of  a  breast-milk. 
In  any  event,  the  relative  proportions  of  the  various  food  elements 
are  correct,  even  if  the  exact  percentages  are  not.  If  the  food  does 
not  agree,  changes  in  the  percentages  to  meet  the  indications 
furnished  by  the  symptoms  will  be  accurate  relatively  to  the 
original  percentages,  which  is  all  that  is  necessary. 

USE   OF  CALORIES  IN   INFANT   FEEDING 

The  calorie  referred  to  in  infant  feeding  is  the  large  calorie,  that 
is,  the  amount  of  heat  necessary  to  raise  one  kilogram  of  water 
1°  C.  A  baby  cannot  thrive  and  gain  unless  its  food  contains  a 
sufficient  number  of  calories  in  a  form  which  can  be  utilized  by  the 
baby.  In  general,  babies  require  from  100  to  120  calories  per 
kilogram  of  body  weight  during  the  first  six  months  in  order  to 
gain,  and  in  the  neighborhood  of  100  calories  during  the  rest  of  the 
first  year.  Ninety  calories  per  kilogram  is  usually  sufficient  during 
the  second  year.  Most  young  babies  will  just  about  hold  their 
weight  on  70  calories  per  kilogram,  a  few  will  gain  regularly  on  this 
amount  while  other  babies  need  as  much  as  140  calories  per  kilo- 
gram in  order  to  gain.  Babies  that  have  been  underfed  or  that  are 
convalescing  from  a  severe  illness,  whether  acute  or  chronic,  need 
more  calories  than  do  normal  babies.  Babies  that  are  fatter  than 
the  average  baby  will  gain  on  fewer  calories  than  will  the  average 
baby.  The  fatter  the  baby  is,  the  fewer  calories  he  needs,  a  very  fat 
baby  often  needing  only  90  calories  per  kilogram.    Conversely,  the 


CALORIES  199 

thinner  or  more  atrophic  a  baby  is,  the  more  calories  it  needs,  many 
extremely  emaciated  babies  requiring  as  much  as  160  calories  per 
kilogram.  Another  factor  which  modifies  the  caloric  need  of  an 
infant  is  its  muscular  activity.  The  quieter  a  baby  is,  the  less 
food  it  requires,  and  vice  versa.  That  is  to  say,  there  is  no  hard 
and  fast  rule  as  to  how  many  calories  a  given  baby  must  have  in 
order  to  gain.  The  calculation  of  the  caloric  value  of  the  food 
will  show  whether  the  failure  to  gain  is  due  to  an  insufficient 
amount  of  food  or  to  some  other  cause.  On  the  other  hand,  if  a 
baby  has  a  disturbance  of  the  digestion  on  a  food  which  seems 
suitable  for  it,  the  calculation  of  the  caloric  value  of  the  food  will 
show  whether  the  disturbance  is  due  to  overfeeding  or  not.  It  must 
be  remembered,  however,  that  while  the  caloric  value  of  a  food 
may  be  high,  the  food  may  be  valueless  to  the  baby,  because  it 
cannot  utilize  it.  Cheese  and  crackers  both  have  a  high  caloric 
value,  but  they  are  not  suitable  articles  of  diet  for  a  three  months' 
old  baby.  A  food  the  caloric  value  of  which  is  high  and  the  com- 
position of  which  is  suitable  for  the  average  baby  may  in  like 
manner  be  of  but  little  value  in  a  given  case.  For  example,  if  a 
baby  with  an  intolerance  for  fat  is  given  a  food  whose  caloric 
value  is  correct  but  which  is  due  in  considerable  part  to  its  fat 
content,  it  will  not  only  not  gain  on  this  food  but  will  be  made  ill. 
On  the  other  hand,  if  the  caloric  value  is  due  to  the  presence  of 
sugar  and  protein,  it  would  be  able  to  utilize  them  and  gain. 
Chapin  has  recently  shown,  moreover,  that  on  accoimt  of  the 
different  powers  of  fat  and  carbohydrates  as  producers  of  meta- 
bolic water,  they  cannot  be  considered  as  interchangeable  as 
regards  favoring  the  growth  of  the  organism.  He  has  also  called 
attention  to  the  fact  that  the  net  caloric  value  of  a  food  depends  on 
the  amount  of  energy  required  for  its  digestion  and  assimilation. 
Foods  having  the  same  gross  caloric  value  may  differ  very  mate- 
rially, therefore,  in  their  net  caloric  value.*  It  has  also  been 
shown  many  times  that  the  caloric  needs  of  an  individual,  whether 
baby  or  adult,  depend  very  largely  on  the  amount  of  exertion 
which  the  iadividual  makes,  the  need  of  food  for  the  produc- 
tion of  energy  depending  on  exertion.  It  is  evident,  therefore, 
that  a  quiet  baby  which  sleeps  all  day  requires  much  less  food 
energy  than  an  active,  restless  baby,  or  one  which  cries  most  of 
the  day. 

It  is  evidently  irrational,  therefore,  to  base  any  scheme  or  system 
of  feeding  on  the  caloric  needs  of  babies  or  on  the  caloric  values 
of  food.    The  calculation  of  the  calories  in  a  given  food  can 
*  Chapin:  New  York  Medical  Journal,  1913,  xcvii,  269. 


200  FEEDING  INTERVALS 

serve  merely  as  a  check.  Used  in  this  way  it  is  often  of  great 
value. 

Intervals  in  Artificial  Feeding. — While,  as  already  stated, 
babies  that  are  nursed  do  much  better  on  the  whole  when  they  are 
fed  at  regular  intervals,  many  of  them  get  along  fairly  satisfac- 
torily and  some  of  them  thrive  perfectly  well,  even  if  fed  at  any 
and  all  times.  This  is  not  the  case  with  artificially-fed  babies. 
They  are  ahnost  certain  to  be  upset  and  suffer  from  disturbances  of 
digestion,  imless  they  are  fed  at  regular  intervals.  Regularity  is 
not  only  advisable  with  them,  as  with  the  breast-fed  baby,  but 
necessary.  In  general,  the  intervals  are  the  same  for  the  artificially 
fed  as  for  the  breast-fed.  It  is  impossible  and  irrational,  however, 
to  lay  down  any  arbitrary  rules  as  to  the  intervals  between  feedings 
at  different  ages.  They  must  vary  with  the  amount  of  food  given 
at  a  feeding,  the  strength  of  the  food  and  its  composition,  as  well 
as  with  the  digestive  capacity  and  gastric  motility  of  the  individual 
infant.  It  is  evident  that  if  a  large  amount  is  given  at  a  feeding, 
the  intervals  between  feedings  must  be  longer  than  when  a  small 
amount  is  given,  as  the  time  required  for  the  stomach  to  empty 
itself  will  be  longer.  The  time  required  for  the  stomach  to  pass  on 
a  food  rich  in  fat  is  greater  than  that  required  to  pass  on  one  poor  in 
fat,  because  fat  delays  the  emptjdng  of  the  stomach.  A  mixture  in 
which  the  protein  is  largely  in  the  form  of  whey  protein  will  leave 
the  stomach  more  quickly  than  one  in  which  the  protein  is  almost 
entirely  casein.  Foods  rich  in  carbohydrates  and  low  in  fat  and 
protein  leave  the  stomach  quickly.  There  is  no  doubt  that  the 
digestive  capacity  and  gastric  motiHty  is  different  in  different 
infants.  It  is  evident,  therefore,  that  the  intervals  must  be  deter- 
mined in  each  case  on  the  conditions  actually  present  in  that  case, 
not  by  any  set  rules. 

Amount  of  Food  at  Single  Feeding. — ^When  a  baby  is  nursed. 
Nature,  under  normal  conditions,  regulates  the  supply  to  the 
demand  and  there  is  no  danger  of  overfeeding.  There  is  no  such 
natural  relation,  however,  between  what  the  person  in  charge  of  a 
baby  may  think  it  requires  and  its  actual  needs.  A  breast-fed 
baby,  while  it  will  take  practically  the  same  amount  of  milk  from 
day  to  day,  does  not  take  the  same  amount  at  each  feeding.  It  will, 
in  fact,  often  take  three  or  four  times  as  much  at  one  feeding  as  it 
does  at  the  next  without  suffering  any  disturbance  of  the  digestion. 
It  has  been  found,  however,  that  it  is  not  safe  to  let  a  baby  take  all 
that  he  will  at  each  feeding  from  an  imlimited  supply  of  artificial 
food.  If  this  method  is  followed,  indigestion  almost  invariably 
results.    In  order  to  avoid  trouble,  the  baby  must  be  given  the 


AMOUNT  OF  FOOD  201 

same  amount  at  each  feeding.  This  amount  is  the  maximum  which 
is  proper  for  the  given  baby.  It  is  not  necessary,  however,  that 
the  baby  always  takes  the  whole  of  it. 

It  is  very  diJEcult,  indeed,  to  know  just  how  much  food  a  baby 
should  take  at  a  feeding.  It  depends  not  only  on  the  age,  but 
also  upon  the  size  of  the  individual  baby.  Some  babies,  moreover, 
require  more  food  than  other  babies  of  the  same  age  and  weight. 
The  amount  of  food  given  at  a  feeding  must  depend  also  on  the 
intervals  between  feedings.  It  is  self-evident  that,  the  twenty- 
four  hour  amount  being  the  same,  more  food  must  be  given  at  a 
feeding  when  the  intervals  are  long  than  when  they  are  short.  The 
amount  of  food  to  be  given  in  24  hours  is  the  most  important  point 
to  be  determined.  When  this  is  decided,  it  must  be  divided  equally 
according  to  the  number  of  feedings  to  be  given.  If  the  twenty- 
four  hour  amount  is  correct,  the  amount  given  at  a  feeding  and  the 
number  of  feedings  are,  within  reasonable  limits,  relatively  un- 
important. The  figures  as  to  the  gastric  capacity  at  different  ages 
are  of  comparatively  Uttle  value  because  of  the  difficulties  and 
inaccuracies  inherent  to  the  various  methods  of  determining  them. 
Even  if  these  figures  were  correct,  they  would  not  be  of  great  value, 
because  of  the  fact  that  more  or  less  of  the  food  ingested  passes 
from  the  stomach  into  the  duodenum  while  it  is  being  taken.  How 
much  passes  varies  undoubedly  in  different  babies  and  in  the  same 
baby  at  different  times. 

Experience  has  shown  that  the  amount  of  food  taken  in  twenty- 
four  hours  increases  rapidly  during  the  first  three  months  and  less 
rapidly  during  the  remainder  of  the  first  year.  The  average  baby 
takes  ten  or  twelve  ounces  at  the  end  of  the  first  week,  twenty 
oimces  when  a  month  old  and  thirty-two  oimces  when  four  months 
old.  It  will  take  thirty-six  to  forty  oimces  at  six  months  and  forty- 
eight  ounces  at  nine  months. 

It  is  evidently  impossible,  therefore,  to  give  any  absolute  figures 
as  to  how  much  food  should  be  given  a  baby  of  a  certain  age.  In 
a  general  way,  however,  the  average  baby  takes  about  one-half 
ounce  at  a  feeding  in  the  first  few  days,  and  an  ounce  to  an  oimce 
and  a  half  when  it  is  a  week  or  ten  days  old.  It  takes  about  two 
and  one-half  oimces  when  it  is  a  month  old,  four  ounces  at  three 
months,  six  ounces  at  six  months  and  eight  ounces  at  nine  months. 
It  is,  as  already  stated,  impossible  to  lay  down  any  hard  and  fast 
rules  as  to  the  intervals  between  feedings  and  the  amount  to  be 
given  at  a  single  feeding  at  given  ages.  The  intervals  and  the 
amount  at  each  feeding  must  vary  with  the  circumstances  in  the 
individual  case.    While  this  is  true,  it  is,  nevertheless,  possible  to 


202 


FEEDING  INTERVALS 


give  certain  figures,  founded  on  what  average  babies  have  been 
found  by  experience  to  have  done  in  the  past,  as  to  what  the 
average  baby  may  be  expected  to  do.  These  figures  must  not  be 
followed  blindly,  but  can  serve  as  a  guide  as  to  what  may  be 
expected  of  an  average  baby  of  a  given  age. 

TABLE  40 


Age 


34-hour  amount 


Number  of  feedings,  amount  and 
intervals 


1  week. 
4  weeks 

4  mos .  . 
6  mos .  . 
9  mos .  . 


10-12  oz. 
20  oz. 

32  oz. 
36-40  oz. 

48  oz. 


10  feedings  of  1  oz.  at  2  hr.  intervals 
l^oz.  2Hhr.      " 

8         "  2|^oz.  2i^hr.      " 

7         "  3oz.      3hr.         " 


4K  oz.  3  hr. 

6  or  6K  oz.  3  hr.         " 

8  oz.      3  hr.         " 
9H  oz.  3  or  4  hr.  " 


Ten  feedings  at  two-hour  intervals  means  every  two  hours  from 
6  A.  M.  to  10  P.  M.  and  once  between  ten  and  six  at  night. 

Eight  feedings  at  two  and  one-half  hour  intervals  means  every 
two  and  one-half  hours  from  6  A.  M.  to  9  P.  M.  or  10  P.  M.,  and 
once  between  the  evening  feeding  and  morning. 

Seven  feedings  at  three-hour  intervals  means  every  three  hours 
from  6  A.  M.  to  10  P.  M,,  and  once  between  ten  and  six  at  night. 

Six  feedings  at  three-hour  intervals  means  every  three  hours 
from  6  A.  M.  to  9  or  10  P.  M. 

Five  feedings  at  three-hour  intervals  means  every  three  hours 
from  6  A.  M.  to  9  P.  M. 

Five  feedings  at  four-hour  intervals  means  every  four  hours  from 
6  A.  M.  to  10  P.  M. 

The  night  feeding  may  be  omitted,  in  many  instances,  before  the 
baby  is  six  months  old.  If  so,  the  amount  which  was  in  this 
bottle  must  be  distributed  among  the  other  bottles  in  order  to  keep 
the  twenty-four  hour  amount  the  same. 

Composition  of  Food  at  Different  Ages. — It  is  impossible  to 
over-emphasize  the  facts  that  babies  cannot  be  fed  by  rule  and 
that  the  food  of  each  baby  must  be  adapted  to  the  digestive 
capacity  of  that  individual  baby.  It  is  equally  true,  however,  that 
young  infants  cannot  take  as  strong  an  artificial  food  as  older 
babies  and  that  the  average  well  baby  thrives  better  on  artificial 
foods  in  which  the  relation  of  the  fat,  sugar  and  protein  in  the 


COMPOSITION  OF  FOOD 


203 


mixture  are  similar  to  those  in  human  milk.  Experience  in  the 
feeding  of  large  numbers  of  well  babies  has  shown  that,  on  the 
average,  babies  of  certain  ages  take,  digest  and  thrive  best  on 
certain  strengths  of  food.  The  expert  in  the  feeding  of  infants  has 
no  need  of  tables  showing  the  average  strength  of  food  taken  at 
different  ages.  He  is  able  to  judge  very  closely  from  the  age, 
appearance  and  past  history  of  the  baby  what  food  is  suitable  for 
it.  These  of  less  experience,  however,  need  such  a  table  to  serve  as 
a  guide  in  the  preparation  of  the  first  mixture  for  a  well  baby  when 
it  comes  into  their  hands,  and  to  show  them  in  a  general  way  what 
the  average  well  baby  may  be  expected  to  take.  In  any  hands,  the 
first  formula  must  always  be  something  of  an  experiment.  After 
this,  the  food  must  be  prepared  to  meet  the  indications  furnished 
by  the  sjTiiptoms,  the  findings  in  the  stools,  the  appearance  and  the 
weight  chart  of  the  individual  baby  at  the  given  time. 

TABLE  41 
CoMPOsmoN  OP  Food  fob  Average  Well  Babies 


Age 

Fat 

Sugar 

Protein 

First  food 

1.00 
2.00 
3.00 
3.50 
4.00 
4.00 
4.00 

5.00 
6.00 
7.00 
7.00 
7.00 
7.00 
7.00 

0.50 

First  week 

0.75 

1  month 

1.00 

2  months 

1.50 

4  months 

1.75 

6  months 

2.25 

8  months 

2.50 

Variation  of  Different  Food  Elements. — It  is  possible  not  only 
to  vary  the  percentages  of  the  different  elements  in  the  food, 
but  also  to  use  these  elements  in  different  forms.  There  are,  for 
example,  several  varieties  of  sugar,  one  of  which  will  agree  in  one 
condition,  another  in  another.  Barley  starch  may  be  used  in  one 
instance,  oat  starch  in  another.  Whey  protein  may  be  given 
instead  of  casein  when  the  latter  causes  disturbance,  or  the  casein 
may  be  partially  digested  by  pancreatization.  Alkalies  may  be 
added  to  the  food  or  lactic  acid  organisms  may  be  grown  in  it,  and 
so  on. 

Fat. — The  amount  of  fat  in  the  food  may  be  varied,  but  the 
character  of  the  fat  cannot  be  changed,  except  in  so  far  as  it  differs 
in  the  milk  of  different  breeds  of  cows.  The  emulsion  of  the  fat 
may  be  made  much  more  complete,  however,  by  means  of  the 
process  known  as  "homogenization,"  by  which  the  fat  droplets 


204  FAT 

are  rendered  extremely  small.  Other  fats,  such  as  olive  oil,  may 
also  be  introduced  into  the  milk  by  this  process.^  It  has  been 
thought  by  some  physicians  that  the  cream  obtained  by  centrifu- 
galization  is  less  suitable  for  the  preparation  of  foods  for  infants 
than  that  obtained  by  gravity.  There  is,  however,  no  proof  that 
this  is  so,  and  the  general  experience  is  that  it  makes  no  difference 
whether  the  cream  is  obtained  by  gravity  or  centrifugalization. 
The  upper  layers  of  cream  which  has  risen  contain  many  more 
bacteria  than  the  lower.  It  is  of  certain  advantage,  therefore,  to 
remove  the  upper  two  ounces  of  cream  from  each  quart  in  order  to 
reduce  the  bacterial  contamination.^ 

Very  few  babies  are  able  to  take  more  than  4%  of  fat  in  their 
food  continuously  without  developing  disturbances  of  digestion  or 
of  nutrition.  More  than  4%  of  fat  should,  therefore,  never  be 
given,  except  for  special  indications,  and,  if  it  is  so  given,  it  should 
not  be  kept  up  for  any  length  of  time.  Most  well  babies  over  three 
months  old  can  take  4%  of  fat  without  any  trouble  resulting. 
Indeed,  in  most  instances  they  thrive  better  on  this  amount  than 
on  lower  percentages.  This  is  not  the  case  with  sick  babies,  how- 
ever, and  here,  as  always,  it  must  never  be  forgotten  that  con- 
clusions as  to  what  is  a  suitable  food  for  a  sick  baby  cannot  be 
drawn  from  what  is  suitable  for  a  well  one.  It  is  safer  when  babies 
are  fed  on  modifications  of  milk  prepared  at  home  not  to  give  more 
than  S}/2%,  or  even  more  than  3%  of  fat,  because,  as  in  most 
methods  of  calculation  the  fat  content  of  the  skimmed  milk  is 
disregarded,  the  foods  always  contain  more  fat  than  they  are 
supposed  to. 

One  of  the  reasons  why  too  high  precentages  of  fat  are  given  is 
the  desire  to  make  the  baby  gain  in  weight.  Mothers  are  always 
and  physicians  not  infrequently  inclined  to  attach  too  much  im- 
portance to  the  weight  chart  and,  believing  that  fat  tends  to 
increase  the  weight  more  than  anything  else,  to  increase  it  unduly 
on  this  account.  As  a  matter  of  fact,  the  fat  baby  is  often  not 
as  strong  and  vigorous  as  the  thinner  baby,  and  fat  in  the  food  is 
no  more  useful  than  carbohydrates  in  increasing  weight. 

Another  reason  why  babies  are  given  excessive  amounts  of  fat  is 
that  most  mothers  and  nurses,  and  unfortunately  many  physicians, 
think  that  fat  always  has  a  laxative  action.  They,  therefore,  in- 
crease the  amount  of  fat  in  the  food  whenever  a  baby  is  con- 
stipated, not  realizing  that  an  excessive  amount  of  fat  is  one  of 
the  most  common  causes  of  constipation  in  infancy.    Increasing 

^  Ladd:  Archives  of  Pediatrics,  1915,  xxxii,  409. 
2  Hess:  Journal  A.  M.  A.  1909,  liii,  523. 


SUGARS  205 

the  percentage  of  fat  in  the  food  in  such  cases,  of  course,  merely 
makes  a  bad  matter  worse. 

The  chief  reason  why  babies  get  excessive  amounts  of  fat  in  their 
food  is  that  physicians  do  not  appreciate  the  fact  that  cream  and 
top  milk  are  indefinite  terms  or  that,  if  they  do  appreciate  this  fact 
and  are  careful  in  their  calculations,  they  are  not  precise  enough  in 
their  directions  as  to  the  preparation  of  the  food.  If  32%  cream  is 
used  in  the  preparation  of  a  milk  mixture,  the  formula  for  which 
was  calculated  on  the  basis  of  16%  cream,  it  is  evident  that  the 
mixture  will  contain  twice  as  much  fat  as  was  intended.  In  the 
same  way,  if  a  top  milk  mixture  is  made  with  a  certain  number  of 
ounces  from  the  top  eight  ounces  instead  of  with  the  same  niunber 
of  ounces  from  the  top  sixteen  ounces  as  ordered,  it  will  contain 
nearly  twice  as  much  fat  as  it  should,  the  fat  content  of  the  top 
eight  ounces  being  13.3%  and  that  of  the  top  sixteen  ounces,  7%. 
The  physician  must  always  decide  what  percentage  cream  or  what 
top  milk  he  will  use  in  the  preparation  of  his  mixture,  and  then 
calculate  the  amount  to  be  used  on  the  basis  of  its  fat  content. 
Otherwise,  the  fat  content  of  the  food  will  never  be  what  he  thinks 
it  is.  He  must  also  give  the  person  who  is  to  prepare  the  food  such 
explicit  directions  as  to  how  to  obtain  the  cream  or  top  milk  that 
she  cannot  possibly  make  a  mistake. 

It  must  be  remembered  on  the  other  hand,  however,  that  the 
caloric  value  of  fat  is  more  than  twice  as  great  as  that  of  the 
carbohydrates  and  protein.  Unless  a  reasonable  amount  of  fat  is 
used  in  the  food,  it  is,  therefore,  often  difficult  to  meet  the  caloric 
needs  without  unduly  increasing  the  quantity  of  the  food. 

Sugars. — Milk  sugar  being  the  only  form  of  sugar  present 
in  human  milk  and  in  the  milk  of  animals,  it  seems  reasonable  to 
suppose  that  it  is  the  sugar  most  suitable  for  the  growth  of  the 
young  organism,  whether  human  or  animal.  It  is  hardly  necessary, 
however,  to  adduce  this  argument  in  favor  of  milk  sugar,  because 
there  are  several  reasons  which  show  that  it  is  the  most  suitable 
form  of  sugar  for  well  infants.  It  is  more  slowly  but  more  com- 
pletely absorbed  than  the  other  disaccharides.  Being  more  slowly 
absorbed,  it  is  present  for  a  longer  time  and  at  lower  levels  of  the 
\intestines  than  the  others,  and  is  thus  more  conducive  to  the 
development  and  persistence  of  the  normal  fermentative  flora 
throughout  the  intestinal  tract.  Few  organisms,  moreover,  other 
than  those  normal  to  the  intestinal  tract  of  infants,  utilize  lactose 
before  it  is  broken  down,  while  many  can  utilize  the  other  double 
sugars.  It  affords,  therefore,  a  more  efficient  protection  against 
abnormal  bacterial  processes  in  the  intestine. 


206  SUGARS 

It  is  probably  true  that  the  net  energy  value  of  milk  sugar  is  less 
than  that  of  malt  sugar,  because  of  the  greater  energy  presumably 
required  for  its  utilization.  It  does  not  seem  probable,  however, 
that  this  difference  is  sufficient  to  be  of  practical  importance.  It 
has  been  suggested  that  on  account  of  the  differences  in  the  salts  of 
human  and  cow's  milk,  the  sugar  in  the  two  milks  may  not  be 
utilized  in  the  same  way.  There  is,  however,  no  proof  of  the 
correctness  of  this  suggestion.  It  has  also  been  claimed  that  the 
lactose  of  cow's  milk  is  not  identical  with  that  of  human  milk. 
There  is,  however,  no  convincing  evidence  in  favor  of  this  claim. 
No  difference  having  thus  far  been  found  in  the  chemical  composi- 
tion of  lactose  from  dijBferent  sources,  it  seems  more  reasonable, 
therefore,  to  consider  them  identical  until  they  are  proved  not  to 
be.  It  must  be  remembered,  however,  that  commercial  milk  sugar 
is  not  always  pure. 

No  more  than  7%  of  milk  sugar  should  be  given  continuously 
in  an  infant's  food.  If  for  any  reason  a  larger  amount  of  sugar  than 
this  is  required,  the  additional  sugar  should  be  given  in  the  form  of 
one  of  the  combinations  of  dextrin  and  maltose.  These  sugars  are 
quickly  absorbed  and  the  intestine  is,  therefore,  not  flooded  with 
an  excess  of  sugar  for  a  long  time,  as  it  would  be  if  milk  sugar  was 
used  exclusively.  Milk  sugar  is  never  found  in  the  urine  or  feces 
under  normal  conditions,  unless  more  than  7%  of  sugar  is  given. 
In  fact,  the  assimilation  Umit  of  milk  sugar,  although  lower  than 
that  of  the  other  disaccharides,  is  far  in  excess  of  the  amount  which 
would  be  contained  in  any  reasonable  food. 

I^actose  in  reasonable  amounts  under  normal  conditions  has  a 
slight  laxative  action,  as  does  maltose,  while  saccharose  is  slightly 
constipating.  When  given  in  excess,  lactose  is  more  likely  than 
the  other  disaccharides  to  cause  diarrhea,  the  order  being  lactose, 
saccharose,  maltose  and  dextrin-maltose  mixtures.  The  probable 
explanation  of  the  greater  frequency  with  which  lactose  causes 
diarrhea  is  its  relatively  slow  absorbability. 

It  is  stated  that  lactose  causes  fever  more  readily  than  the  other 
disaccharides,  the  order  being  lactose,  saccharose  and  maltose. 
The  fever  is  always  accompanied  by  diarrhea,  however,  so  that  the 
presence  of  fever  is  no  argument  against  the  use  of  lactose  in 
reasonable  amounts  under  normal  conditions.  Schlutz's  experi- 
ments render  it  very  improbable,  moreover,  that,  even  when  there 
is  a  rise  in  temperature,  it  is  due  primarily  to  the  sugar.  This  so- 
called  "sugar  fever,"  provided  there  is  such  a  thing,  is,  therefore, 
no  argument  against  the  reasonable  use  of  milk  sugar. 

When  the  disaccharides  are  added  to  a  food  which  contains  Kttle 


SUGARS 


207 


or  no  sugar,  there  is  a  rapid  increase  in  weight  owing  to  the  lessened 
elimination  of  water  by  the  kidneys  as  the  result  of  the  presence  in 
the  organism  of  the  products  of  assimilation  of  the  sugar  absorbed. 
The  difference  in  the  increase  of  weight  with  different  sugars  is 
due  to  the  difference  in  the  quantity  of  Uquid  eliminated  by  the 
kidneys.  The  gain  in  weight  is  more  rapid  with  maltose  and  sac- 
charose than  with  lactose,  probably  because  of  the  easier  assimila- 
tion and  more  rapid  absorption  of  these  sugars.^  This  fact  is  the 
probable  explanation  of  the  sudden  increase  in  weight  which  not 
infrequently  follows  the  change  from  a  modified  milk  prepared  with 
milk  sugar  to  one  of  the  proprietary  foods  containing  some  com- 
pound of  the  dextrins  and  maltose. 

There  can  be  no  doubt,  therefore,  that  under  normal  conditions 
the  preferable  sugar  for  the  well  infant  is  lactose.  This  is  not  the 
case,  however,  in  many  of  the  disturbances  of  digestion.  Some  of 
these  are  due  to  an  excessive  amount  of  milk  sugar  in  the  food. 
They  can  be  quickly  relieved  by  a  reduction  in  the  percentage  of 
milk  sugar.  In  others,  while  the  disturbance  is  not  due  primarily 
to  the  amount  of  milk  sugar,  the  chief  cause  of  the  symptoms  is  the 
fermentation  of  the  milk  sugar  as  the  result  of  abnormal  bacterial 
activity.  In  such  instances  the  milk  sugar  must  be  stopped  and 
some  other  form  of  sugar  substituted  for  it. 

Maltose. — Pure  maltose  is  never  employed  in  the  feeding  of 
infants,  being  altogether  too  expensive  to  be  used  in  this  way. 
The  various  preparations  to  which  this  term  is  erroneously  apphed 
are  mixtures  of  the  various  dextrins  and  maltose.  The  relative 
proportions  of  the  dextrins  and  maltose  are  different  in  all  of  them. 
The  relations  of  the  various  dextrins  to  each  other  are  also  different. 
The  composition  of  a  few  of  these  preparations  is  as  follows: 


TABLE  42 


Food 


Maltose  per  cent. 


Dextrin  per  cent. 


Soxhlet's  Nahrzucker 

Loflund's  Nahrmaltose 

Mead's  Dextri-Maltose 

Neutral  Maltose  (Maltzyme  Co.) .  .  . . 

Loflund's  Malt-Soup  Extract 

Maltose  (Walker-Gordon  Laboratory) 

Mellin's  Food 

Malted  MQk 


52.44 

40.00 

51.00 

63.00-66.00 

58.91 

57.10 

58.88 

49.15* 


41.26 
60.00 
47.00 
8.00-9.00 
15.42 
30.90 
20.69 
18.80 


1  Borrino:  Abstract  in  Archives  of  Pediatrics,  1911,  xxviii, 
*  A  small  proportion  of  the  sugar  is  lactose. 


208  SUGARS 

The  properties  of  maltose  and  the  dextrins  are  materially  differ- 
ent. Maltose  is  a  disaccharide,  dextrins  are  polysaccharides. 
Maltose  is  a  crystalloid,  fermentable  and  dialyzable;  the  dextrins 
are  reversible,  protective  colloids,  non-fermentable  and  non- 
dialyzable.  It  is  evident,  then,  that  it  is  not  a  matter  of  little 
importance  which  of  these  preparations  is  used.  All  are,  of  course, 
eventually  absorbed  in  the  form  of  dextrose.  The  dextrins,  be- 
ing protective  colloids,  in  all  probabihty  have  a  favorable  influence 
on  the  digestibility  of  the  protein  in  the  same  way  as  does  starch. 
Maltose  has  no  such  action.  The  dextrins  have  to  be  changed  to 
maltose  and  then  to  dextrose  before  they  are  absorbed.  The 
larger  the  proportion  of  dextrin  in  the  dextrin-maltose  mixtures, 
the  slower,  therefore,  is  the  absorption  of  sugar  and  vice  versa. 
There  is,  consequently,  less  danger  of  overtaxing  the  absorptive 
mechanism  of  the  intestine  and  of  flooding  the  organism  with 
sugar  when  the  proportion  of  the  dextrins  is  relatively  high.  On 
the  other  hand,  if  it  is  desired  to  give  the  sugar  in  a  form  which 
can  be  very  readily  and  rapidly  absorbed,  the  proportion  of  maltose 
should  be  large.  The  preparations  containing  relatively  large 
amounts  of  maltose  are  more  laxative  than  those  containing  rel- 
atively large  amounts  of  the  dextrins,  because  of  the  larger  amount 
of  sugar  which  is  present  at  one  time  in  the  intestine. 

When  the  dextrin-maltose  preparations  are  prepared  in  the  home 
by  the  action  of  enzymes  on  starch  solutions  the  character  of  the 
product  may  be  varied  to  a  certain  extent.  Temperatures  below 
131°  F.  (55°  C.)  produce  the  largest  amount  of  maltose,  and  above 
145°  F.  (63°  C.)  produce  the  dextrins  in  excess.  A  temperature  of 
167°  F.  (75°  C),  however,  stops  the  action  of  the  enyzmes.  Pure 
maltose  is  never  produced,  because  after  the  concentration  of  the 
maltose  reaches  a  certain  point,  the  further  production  of  dextrin, 
and  therefore  of  maltose,  is  inhibited. 

Maltose  is  split  into  dextrose  and  dextrose  which  can  be  imme- 
diately utiUzed.  Lactose  is  split  into  dextrose  and  galactose,  and 
saccharose  into  dextrose  and  levulose.  Only  the  dextrose  half  of 
these  sugars  is,  therefore,  immediately  available  without  further 
change.  This  immediate  availability  of  the  whole  of  the  malt 
sugar  is  presumably  of  some  advantage  in  feeble,  emaciated  babies, 
who  have  little  or  no  reserve  of  glycogen  in  the  liver,  in  that  all  the 
energy  derived  from  the  sugar  may  be  used  immediately  in  the 
digestion  of  the  rest  of  the  food,  whereas  the  energy  of  the  other 
sugars  is  not  at  once  utilizable,  the  galactose  and  levulose  halves 
having  to  be  converted  into  glycogen  in  the  liver  and  then  recon- 
verted into  maltose  and  dextrose.    The  net  energy  value  of  malt 


SUGARS  209 

sugar  is  also  presumably  somewhat  greater  than  that  of  lactose  and 
saccharose,  because  the  sugar  being  converted  at  once  into  dextrose, 
no  further  energy  is  required,  as  there  is  to  convert  the  galactose 
and  levulose.  The  immediate  utilizability  of  malt  sugar  is  the 
chief  point  in  favor  of  the  employment  of  this  form  of  sugar  in  the 
feeding  of  babies  not  suffering  from  disturbances  of  the  digestion. 
This  fact,  while  of  importance  in  the  feeding  of  feeble  and  ema- 
ciated babies,  who  have  but  httle  or  no  reserve  of  glycogen  in  the 
liver,  is  of  no  advantage  in  the  feeding  of  normal  infants.  In  fact, 
it  is  probably  somewhat  of  a  disadvantage.  Milk  sugar,  which  is 
more  slowly  broken  up  and  more  slowly  stored  in  the  liver  in  the 
form  of  glycogen,  is  more  suitable,  in  that  it  is  less  likely  to  overtax 
the  Uver  and  cause  alimentary  glycosuria  and  excessive  fat  produc- 
tion. 

Maltose,  being  more  quickly  absorbed,  is  less  favorable  to  the 
maintenance  of  the  normal  fecal  flora  than  lactose.  Maltose, 
moreover,  is  especially  conducive  to  the  growth  of  the  bacillus 
acidophilus,  which,  although  normally  present  in  small  numbers,  if 
present  in  large  numbers  is  liable  to  produce  an  excessive  degree  of 
acidity,  and  this  may  cause  irritation  of  the  intestine  and  an  intol- 
erance for  sugar.  Under  normal  conditions,  therefore,  as  far  as 
the  maintenance  of  the  normal  intestinal  flora  is  concerned,  lactose 
is  preferable  to  maltose. 

There  is  a  form  of  indigestion,  chiefly  intestinal,  in  infancy  due 
to  the  fermentation  of  milk  sugar.  In  the  convalescent  stage  of 
this  condition  the  dextrin-maltose  preparations  can  be  given  sooner 
than  lactose  without  causing  a  return  of  the  symptoms.  Their  use 
is,  therefore,  indicated  in  this  condition.  The  preparations  con- 
taining a  relatively  large  proportion  of  dextrins  are  preferable, 
because  they  are  broken  down  more  slowly.  Sugars  are  con- 
traindicated  in  diseases  of  the  intestinal  tract  due  to  the  gas 
bacillus  and  similar  organisms.  Maltose  is  more  harmful  than 
lactose  because  it  undergoes  butyric  acid  fermentation  more 
readily.  Maltose  is  less  suitable  than  lactose  for  the  feeding  of 
infants  ill  with  diseases  due  to  the  bacteria  which  produce  toxic 
substances  from  protein,  and  non-toxic  substances  from  carbo- 
hydrates for  several  reasons.  Lactose  is  more  slowly  broken  down 
and  absorbed  and  consequently  exerts  a  more  prolonged  action. 
In  the  next  place,  few  organisms  except  those  normal  to  the  in- 
testinal tract  of  infants  can  utilize  it  before  it  is  broken  down  by 
hydrolysis.  There  is  also  danger,  as  already  pointed  out,  if  mal- 
tose is  given  freely,  of  encouraging  the  overdevelopment  of  the 
bacillus  acidophilus  and  developing  a  sugar  intolerance. 


210  SUGARS 

Cane  Sugar. — There  seems  to  be  no  evident  reason  for  using 
cane  sugar  in  place  of  milk  sugar  in  feeding  normal  infants  except 
that  it  is  less  expensive.  It  is  true  that  many  infants  thrive  on  it. 
This  fact,  however,  does  not  prove  that  it  is  preferable  to  milk 
sugar,  because  the  average  normal  infant  is  able  to  utilize  lactose, 
saccharose  or  the  dextrin-maltose  mixtures  indiscriminately,  pro- 
vided they  are  not  given  in  excess.  That  is,  normal  babies  that 
thrive  on  cane  sugar  do  so  in  spite  of  it,  not  because  of  it.  Cane 
sugar,  undergoing  as  it  does  alcoholic  fermentation  instead  of 
lactic  acid  fermentation,  is  less  suitable  for  the  development  and 
maintenance  of  the  normal  intestinal  flora  than  milk  sugar.  Grant- 
ing that  the  experimental  evidence  that  the  assimilation  limits  of 
cane  sugar  are  greater  than  those  of  milk  sugar  and  that  it  is  less 
likely  to  cause  diarrhea  and  "sugar  fever"  than  milk  sugar  is 
correct,  which  is  certainly  open  to  question,  even  then  it  is  inferior 
in  all  these  respects  to  the  dextrin-maltose  mixtures.  Therefore, 
if  there  is  any  reason  to  believe  that  there  is  a  disturbance  of  the 
digestion  from  the  presence  of  milk  sugar  in  the  food,  the  dextrin- 
maltose  mixtures  should  be  substituted  for  the  milk  sugar,  not 
cane  sugar.  The  dextrin-maltose  mixtures  are  also  preferable  to 
cane  sugar  in  the  feeding  of  feeble,  emaciated  infants  to  whom  it  is 
desirable  to  give  a  rapidly  utilizable  sugar  because,  like  milk  sugar, 
it  is  only  half  dextrose,  the  levulose  being  available  only  after 
further  changes. 

It  is  stated  that,  when  used  continuously,  cane  sugar  has  a 
slightly  constipating  action,  while  milk  sugar  and  the  dextrin- 
maltose  mixtures  are  slightly  laxative.  This  action  is,  however, 
hardly  strong  enough  to  be  of  any  practical  importance. 

Starch. — It  has  been  proved  beyond  question  that  amylolytic 
ferments  are  present  in  the  saliva  and  pancreatic  secretions  of  the 
new-born  infant,  even  if  it  is  bom  prematurely.  These  ferments 
are  present  and  active  in  the  breast-fed  as  well  as  in  the  artificially- 
fed  infant.  The  amylase  of  the  pancreatic  secretion  is  more  abund- 
ant after  the  first  month  than  earlier.  After  the  first  month  the 
activity  of  the  pancreatic  amylase  seems  to  depend  more  on  in- 
dividual peculiarities  than  on  the  age  of  the  baby.  The  amount 
of  the  secretion  is  apparently  independent  of  the  character  of  the 
food.  It  is  not  diminished  in  atrophic  conditions.  There  are, 
therefore,  no  physiologial  contraindications  to  the  use  of  starch  in 
the  feeding  of  infants,  even  of  the  new-bom.  This  fact  does  not 
prove,  however,  that  infants  ought  always  to  be  given  starch  or 
that  they  should  be  fed  on  foods  composed  largely  or  almost  ex- 
clusively of  starch.    It  merely  shows  that  there  is  no  reason  why 


STARCH  211 

starch  should  not  be  given  to  babies,  if  there  is  any  good  reason  for 
using  it.  Clinical  experience  shows  that,  in  general,  it  is  not 
advisable  to  give  starch  to  babies  under  two  months  old,  although 
there  are  many  exceptions  to  this  general  rule.  Clinical  experience 
also  shows  that  it  is  inadvisable  to  give  large  amounts  of  starch  to 
babies  before  they  are  ten  months  old.  It  shows,  on  the  other  hand, 
however,  that  many  babies  do  far  better  on  foods  containing  starch 
than  they  do  on  foods  which  do  not  contain  it.  Starch  should  be 
used  in  the  food  of  infants  in  the  same  way  as  the  sugars,  fat  and 
protein,  that  is,  intelligently  and  for  definite  purposes  and  indica- 
tions. The  percentage  of  starch  in  the  food  should  be  just  as 
carefully  calculated  as  that  of  any  of  the  other  elements. 

The  caloric  value  of  starch  is,  for  practical  purposes,  the  same  as 
that  of  sugar,  the  loss  of  nutritive  value  resulting  from  the  greater 
energy  expended  in  breaking  down  the  starch  being,  for  every-day 
work,  negUgible.  The  starch  is,  of  course,  ultimately  converted 
into  dextrose  before  it  is  utilized.  Starch  is  used  less  frequently, 
however,  primarily  for  its  nutritive  value  than  for  its  other  prop- 
erties. 

Starch  acts  as  a  protective  colloid  and  in  this  way  prevents  the 
formation  of  large  casein  curds.  This  action  is  due  to  the  soluble 
starch  itself,  not  to  the  salts  or  to  cellulose  in  suspension.  It  has 
been  found  that  percentages  of  starch  greater  than  0.75%  in  milk 
mixtures  have  no  more  effect  in  diminishing  the  size  of  the  curds 
than  does  0.75%,  while  smaller  percentages  have  less  effect.  When 
starch  is  added  simply  for  its  effect  on  the  coagulation  of  casein, 
0.75%  is,  therefore,  the  optimum  amount.^  This  amount  of  starch 
is  very  seldom  outside  of  the  limit  of  tolerance  of  even  the  youngest 
and  feeblest  infant. 

Starch  is  very  useful  when  it  is  desirable  to  give  carbohydrates 
to  infants  in  whom  the  sugars  cause  fermentation  or  in  whom  the 
tolerance  for  sugars  is  so  low  that  they  cannot  be  given  in  sufficient 
quantities  to  supply  the  caloric  needs  which  cannot  be  met  by  fat 
and  protein.  The  probable  reason  that  babies  can  take  carbo- 
hydrate in  the  form  of  starch,  when  they  cannot  take  it  in  the 
form  of  dextrins  and  sugar,  is  that  the  molecular  structure  of 
starch  is  more  compUcated  than  that  of  the  dextrins  and  sugars. 
The  more  complicated  the  structure  of  a  carbohydrate  is,  the  more 
numerous  are  the  steps  in  its  breaking  down  to  its  end  products. 
There  are,  therefore,  less  fermentable  materials  in  the  intestine  at 
one  time  and  less  opportimity  is  afforded  for  fermentation  to  get 
the  upper  hand. 

*  White:  Journal  of  Boston  Society  of  Medical  Sciences,  1900,  v,  125. 


212  STARCH 

Starch  is  used  in  infant  feeding  in  the  form  of  the  cereal  waters 
or  gruels.  The  nutritive  value  of  these  waters  and  gruels  rests  al- 
most entirely  in  the  starch  which  they  contain.  The  cereal  waters 
contain  about  1.50%  of  starch,  0.20%  of  protein  and  from  0.01%  to 
0.05%  of  fat.  The  gruels  contain  about  twice  as  much  of  each 
element.^  When  it  is  remembered  that  these  cereal  preparations 
are  used  merely  as  diluents  it  is  evident  that  the  food  value  fur- 
nished by  the  fat  in  them  is  essentially  nil,  and  that  furnished 
by  the  protein  negligible.  Cereal  diluents  made  from  the  whole 
grains  contain  more  protein,  however,  then  those  made  from  the 
corresponding  flours. 

Starch  is  most  commonly  used  in  the  form  of  barley  or  oat  flour. 
Barley  flour  is  usually  considered  to  be  somewhat  constipating  and 
oat  flour  to  have  a  slightly  laxative  action.  The  action  of  these 
flours  on  the  intestinal  peristalsis  is,  however,  not  at  all  a  constant 
one,  barley  starch  having  a  laxative  and  oat  starch  a  constipating 
action  in  some  infants.  Other  forms  of  starch  have  been  used  but 
little  in  this  country  and  it  has  been  rather  taken  for  granted  that 
it  makes  but  Httle  difference  what  form  of  starch  is  used.  This  is 
probably  true  in  most  instances  and  when  small  amounts  only  are 
used.  The  investigations  of  Nagao  ^  and  Klotz,^  show  that  barley 
and  oat  starch  are  broken  down  more  rapidly  by  enzymes  and  bac- 
teria than  are  wheat  and  rye  starch.  The  former  flours  are  more 
likely,  therefore,  to  cause  acidity  and  fermentation  than  the  latter. 

It  must  not  be  forgotten,  however,  that,  while  starch  in  reason- 
able amounts  is  often  most  useful  in  feeding  infants,  it  may,  if 
given  in  excessive  amounts,  cause  very  marked  disturbances  of 
digestion  and  of  nutrition.  The  fermentation  of  starch  results  in 
the  formation  of  free  fatty  acids,  which  exert  a  strong  irritant 
action  on  the  intestines  and  cause  increased  peristalsis.  The  in- 
jurious effect  of  these  acids  is  the  same,  whether  they  are  derived 
from  carbohydrates  or  fat.^ 

On  the  other  hand,  an  excessive  amoimt  of  starch  not  infre- 
quently causes  constipation.  The  stools  in  such  cases  are  hard, 
dry  and  Ught-brown,  resembling  the  soap  stool  except  in  their  color. 

A  baby  on  a  purely  carbohydrate  diet  or  on  one  in  which  the 
carbohydrates  are  greatly  in  excess  receives  much  less  salts  than  it 
should,  such  a  diet  being  poor  in  salts.  The  consequent  disturb- 
ance in  the  retention  of  salts  and  water  results  in  impairment  of 

^  Ladd:  Archives  of  Pediatrics,  1908,  xxv,  256. 

'  Nagos:  Zeitschr.  f.  experiment.  Path.  u.  Therapie,  1911,  ix,  227. 

*  Klotz:  Archiv.  f.  experiment.  Path.  u.  Pharmacol.,  1912,  Ixvii,  451. 

*  Stolte:  Jahrb.  f.  Kinderheilkunde.,  1911,  Ixxiv,  367. 


POLYCARBOHYDRATES  213 

the  nutrition  and  in  marked  diminution  in  the  resistance  to  infec- 
tion.* Serious  disturbances  of  nutrition  from  the  excessive  use 
of  starchy  foods,  although  apparently  common  abroad,  are  fortu- 
nately comparatively  rare  in  this  country. 

Polycarbohydrates. — Attention  has  recently  been  called  to  the 
use  of  "polycarbohydrates"  in  infant  feeding.  Those  who  use 
this  term  mean  by  it  a  combination  of  several  carbohydrates  in  the 
same  food.  They  beheve  that,  on  account  of  the  difference  in  the 
rapidity  of  absorption  of  the  different  carbohydrates,  more  car- 
bohydrate can  be  given  in  this  way  without  overtaxing  the  power 
of  the  organism  to  assimilate  and  utilize  sugar  than  when  a  single 
carbohydrate  is  used.  This  belief  is  unquestionably  correct  and 
there  is  no  doubt  that  when  there  is  a  disturbance  in  the  digestion 
of  sugar  it  is  of  great  advantage  to  give  some  of  the  carbohydrate 
in  the  form  of  starch.  The  rationale  of  the  use  of  the  dextrin- 
maltose  mixtures  and  starch  has  aheady  been  considered  in  dis- 
cussing these  substances.  Those  who  advocate  the  use  of  "poly- 
carbohydrates" in  infant  feeding  seem  to  forget,  however,  that 
mixtures  of  milk  and  cereal  waters  contain  two  carbohydrates, 
milk  sugar  and  starch,  and  mixtures  of  milk,  dextrin-maltose  mix- 
tures and  cereal  waters  four  carbohydrates,  milk  sugar,  malt  sugar, 
dextrins  and  starch.  The  principle  is,  therefore,  not  a  new  one. 
Owing  to  the  inferiority  of  cane  sugar  to  the  other  sugars  as  a  food 
for  infants  and  the  comparatively  slight  difference  in  the  fer- 
mentabihty  of  the  various  forms  of  starch,  it  hardly  seems  neces- 
sary to  complicate  the  mixtures  further  by  the  addition  of  cane 
sugar  and  by  the  use  of  several  varieties  of  starch  in  the  same  food. 
The  mixtures  of  milk,  dextrin-maltose  mixtures  and  simple  cereal 
waters  contain  the  carbohydrates  in  sufficient  variety  to  meet  the 
indications  for  the  "polycarbohydrates."  The  malt  sugar  is  ab- 
sorbed first,  then  the  milk  sugar,  next  the  dextrins  and  finally 
the  starch.  The  absorption  is  thus  comparatively  slow  and  con- 
tinues for  a  long  time.  The  sudden  flooding  of  the  organism  with 
sugar  is  thus  avoided. 

Protein. — ^While  the  fats  and  carbohydrates  can,  with  certain 
restrictions  which  have  been  considered  elsewhere,  be  used  inter- 
changeably in  feeding  babies,  neither  can  take  the  place  of  protein. 
The  protein  is  essential  to  fife,  in  that  it  is  the  only  form  of  food 
which  can  replace  the  nitrogenous  waste  of  the  body  and  from 
which  new  cells  can  be  built  up.  It  is  indispensable  for  the  repair 
and  growth  of  the  body.  New  tissue  cannot  be  formed  from 
carbohydrates  and  fat.  They  serve  as  sources  of  energy.  Protein 
iSalge:  Jahrb.  f.  Kinderheilkunde.,  1912,  Ixxvi,  125. 


214  PROTEIN 

can  also  serve  as  a  source  of  energy  and  life  can  be  sustained  for 
considerable  periods  of  time  on  a  purely  protein  diet.  Such  a  diet 
is,  however,  a  wasteful  one,  throws  an  excessive  amount  of  work 
on  the  organs  of  digestion  and  metabolism  and  seriously  overtaxes 
the  organs  of  elimination. 

The  protein  need  of  the  infant  is  much  greater  than  that  of  the 
adult,  in  that  it  not  only  requires  protein  to  replace  tissue  waste  but 
also  to  build  up  new  tissues.  If  the  protein  content  of  its  food  is 
below  a  certain  level,  it  will  eventually  die  of  malnutrition,  no 
matter  how  high  the  caloric  value  of  the  food.  If  the  protein 
content  is  just  high  enough  to  cover  the  tissue  waste  and  a  Uttle 
more,  the  baby  will  live,  but  it  will  not  thrive  properly.  It  may 
become  fat,  but  it  cannot  form  bone  and  muscle  as  it  should.  The 
cause  of  anaemia,  obscure  disturbances  of  nutrition,  delay  in  mus- 
cular development  and  various  functional  derangements  of  the 
nervous  system  in  infancy  is  not  infrequently  a  deficiency  of  pro- 
tein in  the  food.  The  average  protein  need  of  infants  is  at  least  1.5 
grams  per  kilogram,  or  0.7  grams  per  pound  of  body  weight. 
In  all  probability,  many  babies  require  as  much  as  2  grams  per 
kilogram,  or  0.9  grammes  per  pound  of  body  weight.  Unless  a 
baby  gets  this  amount  of  protein  in  its  food,  it  cannot  thrive.  It 
can  often  take  much  more  than  this  with  advantage. 

The  most  available  and  the  most  easily  digestible  form  of  pro- 
tein for  infants  is  the  protein  of  milk.  The  protein  of  woman's  milk 
is  more  digestible  than  that  of  cow's  milk.  A  part  of  the  protein 
may  be  given  in  the  form  of  vegetable  protein,  but  vegetable  pro- 
tein cannot  permanently  replace  animal  protein  in  the  infant's 
food. 

There  is  no  doubt  that  the  opinion  held  some  years  ago  that  the 
protein  was  the  most  indigestible  portion  of  cow's  milk  for  infants 
and  that  the  disturbances  of  digestion  occurring  in  infants  fed  on 
cow's  milk  were  almost  entirely  due  to  the  protein,  was  an  erro- 
neous one.  It  is  probable,  on  the  other  hand,  that  at  the  present 
time  the  tendency  is  to  minimize  the  possible  power  of  protein  to 
cause  disturbances  of  digestion  and  metabolism  and  to  attach  too 
little  importance  to  it.  One  cause  for  this  tendency  is  presumably 
that  the  disturbances  caused  by  the  proteins  are,  like  those  caused 
by  the  salts,  less  easily  recognizible  than  those  caused  by  the 
carbohydrates  and  fats.  It  has  recently  been  shown,  for  example, 
than  an  excessively  high  protein  diet  will  cause  fever  ^  and  a  con- 
dition of  semistupor.^    The  products  of  protein  metabolism,  when 

^  Holt  and  Levene:  American  Journal  of  Diseases  of  Children,  1912,  iv,  265. 
*  Hoobler:  American  Journal  of  Diseases  of  Children,  1915,  x,  153. 


PROTEIN  215 

in  excess,  undoubtedly  irritate  the  kidneys.  Further  undesirable 
results  of  an  excessive  amount  of  protein  will,  in  all  probabiUty, 
be  discovered  as  the  subject  is  more  carefully  studied. 

The  relation  of  the  casein  to  the  whey  protein  in  human  milk  is 
approximately  as  1  is  to  2,  while  the  relation  in  cow's  milk  is  as 
3  to  1.  While  it  is  possible,  and  perhaps  probable,  that  there  are 
considerable  chemical  differences  between  the  protein  of  human 
milk  and  that  of  cow's  milk,  this  is  not  proven.  Setting  aside,  how- 
ever, the  undoubtedly  important  but  still  problematical  action 
of  the  salts  of  the  two  milks  on  the  digestibility  of  the  protein,  in 
the  light  of  our  present  knowledge,  the  chief  cause  of  the  difference 
in  the  digestibility  of  the  protein  of  human  milk  and  that  of  cow's 
milk  lies  in  the  greater  proportion  of  casein  in  cow's  milk.  In  the 
first  place,  the  absolutely  greater  amount  of  casein  in  cow's  milk 
favors  the  formation  of  large,  tough,  casein  curds,  while  the  rela- 
tively smaller  proportion  of  the  whey  protein  to  casein  diminishes 
its  colloidal  action  in  the  prevention  of  the  coagulation  of  the 
caseiQ. 

It  is  the  formation  of  large  curds  which  renders  the  casein  of 
cow's  milk  so  much  more  difficult  of  digestion  by  the  infant  than 
that  of  human  milk.  If  the  formation  of  large  casein  curds  in  the 
stomach  can  be  prevented,  the  casein  of  cow's  milk  is  easily  di- 
gested. Fortunately,  the  average  normal  infant  can  digest  con- 
siderable amounts  of  cow's  milk  casein  in  the  usual  dilutions  with- 
out an3rthing  being  done  to  prevent  the  formation  of  large  casein 
curds.  It  is  of  a  certain  disadvantage,  moreover,  to  render  the 
digestion  of  the  casein  too  easy,  because,  if  this  is  done,  the 
development  of  the  digestive  powers  is  not  encouraged  as  it 
should  be. 

Methods  of  Preventing  the  Formation  of  Casein  Curds.  Re- 
duction of  the  Amount  of  Casein. — The  simplest  method  of  pre- 
venting the  formation  of  casein  curds  is  by  diminishing  the  amount 
of  the  casein  and  thus  giving  it  more  diluted.  In  using  this  method, 
however,  great  care  must  be  exercised  not  to  reduce  the  casein 
so  much  that  the  protein  need  is  not  covered.  Some  other  method 
is,  therefore,  usually  preferable. 

Whey  Mixtures. — One  of  the  best  methods  of  giving  the  pro- 
tein in  an  easily  digestible  form  is  the  whey  mixture.  The  whey 
protein  is  not  coagulable  by  rennin  and,  therefore,  cannot  form 
curds.  Moreover,  by  its  colloidal  action  it  hinders  the  formation 
of  large,  casein  curds.  The  presence  of  the  protein  in  the  whey 
makes  it  possible  to  diminish  the  casein  materially  without  in- 
curring the  danger  of  protein  starvation  which  is  always  present 


216  PROTEIN 

when  the  casein  is  reduced  by  simple  dilution.  The  whey  mixture 
is  less  valuable  when  the  food  is  prepared  at  home  than  when  it  is 
prepared  at  a  milk  laboratory,  because,  when  gravity  cream  is  used, 
as  it  has  to  be  in  the  home,  the  amount  of  cream  which  has  to  be 
used  in  order  to  have  sufficient  fat  in  the  mixture  carries  with  it  a 
considerable  percentage  of  casein  and  consequently  reduces  the 
amount  of  protein  which  can  be  given  in  the  whey.  When  whey 
mixtures  are  prepared  at  a  milk  laboratory,  however,  where  high 
percentage  creams  can  be  used,  the  casein  can  be  made  very  low 
and  the  whey  protein  high. 

Whey  mixtures  are  also  very  useful  when  there  is  much  vomiting, 
the  whey  protein,  not  being  acted  on  by  rennin,  leaving  the 
stomach  very  rapidly. 

Cereal  Diluents. — Another  method  of  hindering  the  forma- 
tion of  large,  casein  curds  is  by  the  addition  of  cereal  diluents, 
such  as  barley  water,  to  the  food.  The  soluble  starch  in  these 
cereal  diluents  acts  as  a  protective  colloid.  The  salts  and  the 
suspended  cellulose  probably  play  no  part  in  the  action  of  these 
diluents.  It  has  been  found  that  percentages  of  starch  greater 
than  0.75  in  milk  mixtures  have  no  more  effect  in  diminishing  the 
size  of  the  curds  than  does  0.75%,  while  smaller  percentages  are 
less  effective.  When  a  cereal  diluent  is  added  to  an  infant's  food 
for  the  purpose  of  preventing  the  formation  of  large,  casein  curds, 
it  should,  therefore,  be  added  in  such  a  way  that  the  starch  con- 
tent of  the  mixture  is  0.75%. 

Boiling. — One  of  the  most  effective,  as  well  as  one  of  the  sim- 
plest, methods  of  preventing  the  formation  of  large,  casein  curds 
is  the  boiling  of  the  food.  When  rennin  is  added  in  vitro  to  raw 
milk  and  the  mixture  kept  at  the  proper  temperature,  a  dense, 
hard  coagulum,  which  separates  completely  from  the  whey,  is 
quickly  formed.  When  rennin  is  added  to  boiled  milk,  however, 
coagulation  takes  place  more  slowly,  and  the  curd  which  is  formed 
is  soft  and  fine.  The  separation  of  the  curd  and  whey  is  also 
much  less  complete  than  in  raw  milk,  so  that  the  appearance  of  the 
hquid  is  that  of  a  thick  homogeneous  fluid.  The  experiments  of 
Brennermann  ^  and  others  show  that  the  same  differences  in  the 
coagulation  of  the  casein  of  raw  and  boiled  milk  by  rennin  exist 
in  the  stomach  as  in  vitro.  The  food  must  be  boiled  hard  at  least 
five  minutes  in  a  single  boiler  in  order  to  prevent  the  formation 
of  large  curds.   Simmering  in  a  double  boiler  is  not  effective. 

Alkalis. — The  addition  of  an  alkaU  to  milk  unquestionably 
hinders  or  prevents  the  formation  of  large,  hard  curds  in  the 
» Journal  A.  M.  A.,  1913,  Ix,  575. 


PROTEIN  217 

stomach.  There  is  much  difference  of  opinion  as  to  exactly  how  it 
does  this  and  as  to  exactly  what  chemical  changes  take  place  in 
the  gastric  digestion  of  casein  as  the  result  of  the  addition  of  an 
alkali.  The  most  probable  explanation  of  these  differences  of 
opinion  is  that  the  exact  details  of  the  digestion  of  casein  are  even 
now  but  imperfectly  understood.  The  nomenclature  of  the  various 
products  which  are  formed  is,  moreover,  not  a  settled  one.  The 
coagulation  of  the  milk  in  the  stomach  by  rennin  is  unquestionably 
delayed  by  the  addition  of  an  alkali,  because  rennin  does  not  act  in 
an  alkaline  medium.  How  much  it  is  delayed  depends,  with  a 
given  amount  of  alkali,  on  the  acidity  of  the  milk,  which  in  clinical 
work  is  always  an  unknown  quantity.  The  more  acid  the  milk,  the 
more  of  the  alkali  is  required  to  neutraUze  it  and  the  less  is  left  to 
neutraUze  the  hydrochloric  acid  secreted  by  the  stomach  and  vice 
versa.  When  pure,  clean  milk  is  used,  the  part  played  by  the 
acidity  of  the  milk  is  probably  relatively  unimportant.  During 
this  period  of  delay  it  is  generally  beheved  that  some  of  the  un- 
coagulated  milk  leaves  the  stomach,  the  amount  of  milk  which 
passes  into  the  duodenum  varying  directly  with  the  length  of  time 
before  coagulation  takes  place.  Certain  authorities  claim  that  the 
milk  cannot  leave  the  stomach  under  these  conditions,  because  the 
pylorus  does  not  open  until  the  reaction  on  the  stomach  side  is 
acid.  Others  state  that  milk,  before  it  is  coagulated,  leaves  the 
stomach  quickly  in  gushes,  like  water,  independent  of  the  pyloric 
reflex.^  When  coagulation  does  occur  the  curds  formed  are  more 
granular  and  softer  than  the  tough  curds  of  calcium  paracasein 
which  are  ordinarily  formed. 

Whatever  the  action  of  the  alkali  may  be,  there  is  no  doubt  that 
it  consists  partly  in  neutraUzing  the  acidity  of  the  milk  and  partly 
in  neutralizing  the  hydrochloric  acid  secreted  by  the  stomach, 
thereby  changing  the  combination  of  the  calcium  salts  with  casein. 
It  is  evident,  therefore,  that,  as  regards  the  neutralization  of  the 
acidity  of  the  milk,  whatever  alkali  is  used,  the  amount  to  be 
added  to  the  food  should  be  determined  by  the  amount  of  milk  and 
cream  in  the  food,  which  determine  its  acidity  and  which  alone 
contain  casein,  not  in  relation  to  the  total  quantity  of  the  mixture. 
It  is  impossible  in  ordinary  clinical  work  to  know  how  much  alkali 
to  add,  because  the  acidity  of  the  milk  is  always  an  unknown 
quantity.  Experience  has  shown,  however,  that,  when  lime  water 
is  used  as  the  alkali,  from  25  to  50%  of  lime  water  must  be  added 
to  average  milk  in  order  to  produce  any  appreciable  effect.  The 
alkaline  action  of  lime  water  is  less  than  would  be  expected,  be- 
1  Cannon:  The  Mechanical  Factors  of  Digestion,  1911,  p.  115. 


218  PROTEIN 

cause  of  the  using  up  of  its  soluble  alkalinity  in  the  precipitation 
of  insoluble  calcium  phosphate  in  the  milk.^ 

Bicarbonate  of  soda  or  other  alkalis  are  sometimes  used  in  place 
of  lime  water.  One  and  one-half  grains  of  bicarbonate  of  soda  is 
equal  to  about  ah  ounce  of  lime  water.  The  action  of  lime  water 
and  bicarbonate  of  soda  is,  however,  somewhat  different.  Lime 
water  swells  the  mucoid  protein  of  milk,  which  probably  has  some 
effect  on  the  precipitation  of  the  casein,  while  the  carbonic  acid 
gas  which  is  formed  from  bicarbonate  of  soda  during  digestion  tends 
to  make  the  curds  more  porous. 

Citrate  of  Soda. — Citrate  of  soda  is  of  considerable  value  in 
the  prevention  of  the  formation  of  large,  tough  curds.  Under 
ordinary  conditions  rennin  splits  calcium  caseinate  into  calcium 
paracaseinate  which  is  insoluble.  The  citrate  of  soda  combines 
with  the  calcium  caseinate  of  the  milk  to  form  sodium  caseinate 
and  calcium  citrate.  Rennin  splits  sodium  caseinate  into  sodium 
paracaseinate,  which  is  very  soluble.  Therefore  no  precipitation 
or  curdling  takes  place.^  One  or  two  grains  of  the  citrate  of 
soda  to  the  ounce  of  milk  or  cream  in  the  mixture  is  the  quantity 
usually  employed.  Two  grains  to  the  ounce  is  probably  more 
effective  than  one  grain. 

Buttermilk. — ^The  casein  in  buttermilk  and  other  forms  of  milk 
in  which  lactic  acid  forming  organisms  have  been  allowed  to  grow 
is  in  a  form  in  which  it  cannot  be  acted  upon  by  rennin.  The 
formation  of  large,  hard  curds  is,  therefcwe,  prevented.  The  casein 
is  said  to  be  in  the  form  of  the  lactate  of  casein,  this  having  been 
formed  as  the  result  of  the  combination  of  the  lactic  acid  produced 
by  the  bacteria  with  the  casein.  This  statement  seems  very 
doubtful,  however,  as  casein  acts  as  an  acid  and  two  acids  cannot 
combine.  Some  of  the  casein  has  also  presumably  been  more  or 
less  digested  by  bacterial  action.  The  casein  in  buttermilk  is  in  a 
finely  divided  condition  as  the  result  of  the  mechanical  action  of 
the  churning.  Boiling  buttermilk  does  not  affect  the  chemical 
combination  of  the  casein. 

Protein  Milk. — A  considerable  part  of  the  casein  in  the  so-called 
Eiweissmilch  or,  in  EngUsh,  protein  or  albumin  milk,  has  already 
been  precipitated  by  rennin  in  the  form  of  calcium  paracasein. 
When  taken  into  the  stomach  it,  therefore,  cannot  be  acted  upon 
again  by  rennin.  The  paracasein  curds  have  been,  moreover,  very 
finely  divided  by  being  rubbed  through  sieves  in  the  preparation  of 

*  Bosworth  and  Bowditch:  Joum.  Biolog.  Chem.,  1916-17,  xxviii,  431. 

*  Bosworth  and  Van  Slyke:  Technical  Bulletin  No.  34,  New  York  Agri- 
cultural Experinient  Station. 


SALTS  219 

the  food.  The  casein  furnished  by  the  buttermilk  in  the  food  is,  as 
has  abeady  been  explained,  in  the  form  of  the  "lactate  of  casein." 
The  formation  of  large,  tough  curds  in  the  stomach  is,  therefore, 
impossible. 

Pancreatization. — Another  method  of  preventing  the  formation 
of  large  curds  is  by  the  partial  predigestion  of  the  food.  This 
is  commonly  known  as  peptonization  but  is  in  reality  pancreatiza- 
tion, the  active  ferment  being  the  trypsin  of  the  pancreas.  A  part, 
at  least,  of  the  casein  is  so  far  digested  that  it  cannot  be  acted 
upon  by  rennin.  The  formation  of  hard  curds  in  the  stomach  is, 
therefore,  more  or  less  interfered  with,  the  amount  of  interference 
depending  on  how  far  the  process  of  pancreatization  has  been 
carried. 

Salts. — The  various  salts,  with  the  exception  of  iron,  are  present 
in  sufficient  quantities  and  in  proper  proportions  in  human  milk. 
In  most  modifications  of  cow's  milk  there  is  an  excess  of  salts  and 
the  proportions  of  the  various  salts  are  different  from  those  in 
human  milk.  The  normal  infant  can,  as  a  rule,  thrive  in  spite  of 
this  excess  of  salts  and  in  spite  of  their,  for  the  infant,  abnormal 
relation  to  each  other.  There  is  no  doubt,  however,  that  a  part, 
perhaps  a  considerable  part  of  the  disturbances  of  digestion  in 
infants  fed  on  modifications  of  cow's  milk  are  due  to  the  excess  and 
abnormal  relations  of  the  salts  in  them.  It  does  not  seem  reason- 
able, nevertheless,  to  go  as  far  as  some  pediatricians  and  attribute 
all  the  disturbances  of  digestion  to  them.  At  present,  however,  our 
knowledge  concerning  the  salts,  the  part  which  they  play  in  normal 
digestion  and  metabolism  and  the  symptoms  of  the  disturbances 
which  they  cause  is  so  limited  and  incomplete  that  we  can  pay  but 
little  attention  to  them  in  the  regulation  of  the  diet  either  in  health 
or  in  disease. 

The  Relation  of  the  Different  Elements  of  the  Food  to  Each 
Other. — Thus  far  the  different  elements  of  the  food  and  the  dis- 
turbances of  digestion  to  which  they  may  give  rise  have  been  con- 
sidered as  if  they  always  occurred  independently  of  each  other. 
This  point  of  view  is,  however,  a  mistaken  one.  It  is  wrong  to 
think  so  much,  as  is  now  the  custom,  of  the  disturbances  of  diges- 
tion caused  by  single  elements  of  the  food.  There  can  be  no  doubt 
that  in  many  instances  in  which  the  disturbance  appears  to  be 
due  to  a  single  element,  the  real  trouble  is  in  the  relation  of  the 
different  elements  to  each  other.  Our  knowledge  of  the  connection 
of  the  disturbances  of  digestion  with  the  various  food  elements  is 
still  extremely  rudimentary,  and  we  must  be  very  careful  not  to 
accept  each  new  item  of  information  as  the  final  solution  of  the 
problem.. 


220  BUTTERMILK 

Special  Preparations  of  Milk  used  in  Infant  Feeding. — Various 
special  preparations  of  milk  have  been  used  in  infant  feeding  with, 
according  to  those  who  have  employed  them,  unusually  favorable 
results.  The  most  important  of  them  are  buttermilk  and  protein 
milk. 

Buttermilk. — Buttermilk  made  from  sweet  milk  in  the  manufac- 
ture of  butter  is,  of  course,  nothing  but  skimmed  milk.  It  con- 
tains from  0.50%  to  1.0%  of  fat,  about  4.5%  of  milk  sugar  and 
3.8%  of  protein,  the  relation  of  the  casein  and  the  whey  protein 
being  the  same  as  in  whole  milk. 

Buttermilk  is  usually  made  from  cream  soured  either  naturally 
or  by  the  addition  of  lactic  acid  bacteria.  The  composition  of 
buttermilk  obtained  in  this  way  is  not  a  constant  one.  Average 
figures  are:  fat,  0.5%  to  1.0%;  milk  sugar,  3.0%  to  3.5%;  pro- 
tein, 2.5%  to  2.7%.  The  proportion  of  whey  protein  is  relatively 
higher  than  in  whole  milk.  The  casein  is  very  finely  divided  as  the 
result  of  the  centrifugalization  and  is  separated  from  its  calcium 
base.  It  is  already  clotted  in  the  form  of  the  "lactate  of  casein" 
and  can  no  longer  be  acted  upon  by  rennin.  The  caloric  value  of 
buttermilk  varies  between  300  and  400  calories  per  Hter.  A  fair 
average  figure  is  360  calories  per  quart. 

Good  buttermilk  should  not  contain  over  0.50%  of  lactic  acid. 
There  is  a  tendency  for  the  acidity  to  increase  with  time,  although 
it  rarely  reaches  over  0.75%,  at  which  point  the  buttermilk  sep- 
arates into  curds  and  whey.  The  lactic  acid  organisms  which 
caused  the  souring  of  the  milk,  as  well  as  other  organisms,  are  alive 
and  active.  Heating  buttermilk  destroys  the  fine  division  of  the 
casein  and  causes  it  to  clot  in  large  masses  Hke  ordinary  cow's 
milk.  It  also  destroys  the  bacteria  which  it  contains.  Heated 
buttermilk  is,  therefore,  no  better  than  sour  skimmed  milk.  This 
clotting  may  be  prevented  by  constant,  violent  stirring  or  beating 
while  it  is  being  heated. 

Buttermilk  has  been  used  as  a  food  for  infants  since  at  least  as 
early  as  1770,  and  good  results  have  unquestionably  been  obtained 
with  it.  This  is  readily  understood  when  its  composition  is  remem- 
bered. It  contains  a  low  percentage  of  fat,  a  rather  low  percentage 
of  sugar  and  a  relatively  high  percentage  of  protein,  the  proportion 
of  whey  protein  being  relatively  greater  than  in  plain  milk.  The 
casein  is  finely  divided  and  in  a  form  which  cannot  be  acted  on  by 
rennin.  It  is  highly  acid  from  the  presence  of  lactic  acid  and  con- 
tains many  bacteria,  the  lactic  acid  forms  predominating.  It 
should  be  useful,  therefore,  in  those  conditions  in  which  a  low  fat 
and  a  high,  easily  digestible  protein  is  indicated.    The  lactic  acid 


BUTTERMILK  221 

organisms  which  it  contains  should  also  be  of  advantage  in  those 
disturbances  of  digestion  which  are  due  to  organisms  to  which 
the  lactic  acid  bacteria  are  antagonistic.  This  possible  advantage 
is  lost,  of  course,  when  buttermilk  is  pasteurized  or  boiled. 

Most  of  those  who  have  employed  and  recommended  the  use  of 
buttermilk  as  a  food  for  infants  have,  however,  not  used  it  plain. 
They  have  added  from  10  to  25  grams  of  flour,  usually  wheat, 
and  from  35  to  90  grams  of  cane  sugar  to  a  Uter  of  buttermilk  and 
then  boiled  it  with  much  stirring.  The  nutritive  value  of  the 
buttermilk  is  thus  materially  increased,  while  the  other  char- 
acteristics are  unchanged,  except  that  the  lactic  acid  bacteria  are 
destroyed.  The  caloric  value  of  buttermilk  prepared  in  this  way 
varies  between  525  and  700  calories  per  liter,  the  additional 
calories  being  furnished  by  the  cane  sugar  and  starch  which  have 
been  added. 

It  does  not  seem  rational  to  use  buttermilk,  with  or  without  the 
addition  of  cane  sugar  and  starch,  as  a  routine  food  for  all  babies, 
whether  sick  or  well.  It  is  far  more  reasonable  to  adopt  the  good 
points  in  it  and  utilize  them  in  combination  with  percentage  feed- 
ing.* There  is  no  special  advantage  in  using  buttermilk  in  cases  in 
which  a  low  percentage  of  fat  is  indicated,  because  a  low  percentage 
of  fat  can  be  more  easily  given  in  other  ways.  The  pecuUar  form  of 
the  casein  in  buttermilk  may  be  of  considerable  value  in  instances 
in  which  there  is  a  disturbance  of  the  digestion  of  casein.  If  plain 
buttermilk  or  stock  preparations  of  buttermilk  are  used,  the 
percentages  of  fat  and  sugar  cannot  be  varied  to  suit  the  needs  of 
the  individual  baby.  If  a  modified  milk  is  prepared  to  fit  the  needs 
of  the  individual  infant  at  the  time  and  the  character  of  the  casein 
then  changed  by  the  action  of  lactic  acid  bacteria,  the  chief  ad- 
vantage of  buttermilk  is  thus  retained  and  yet  the  food  is  in  other 
ways  fitted  to  the  needs  of  the  baby.  It  is  probable  that  the 
degree  of  the  acidity  of  the  buttermilk  plays  some  part  in  its 
action.  This  cannot  be  r^ulated  in  commercial  buttermilk,  but 
can  be  when  the  milk  is  soured  by  the  addition  of  lactic  acid 
bacteria,  since  the  production  of  acid  can  be  stopped  at  any  time 
by  boiling  the  mixture.  When  the  change  in  the  character  of  the 
protein  is  all  that  is  desired,  the  mixture  should  be  boiled  when  the 
acidity  is  between  0.25%  and  0.50%.  Twenty-five  hundredths 
per  cent  of  lactic  acid  just  curdles  milk  while  0.50%  gives  thick 
curdled  milk.  An  acidity  of  from  0.50%  to  0.70%  is  usually  at- 
tained in  from  twelve  to  eighteen  hours. 

When  the  action  of  the  lactic  acid  bacteria  on  the  intestinal 
*  Morse  and  Bowditch:  Archives  of  Pediatrics,  1906,  xxiii,  889. 


222  PROTEIN  MILK 

bacteria  is  what  is  desired,  the  mixture  should  not,  of  course,  be 
boiled.    The  acidity  should  not,  however,  run  much  above  0.50%. 

Other  objections  to  the  use  of  commercial  buttermilk  are  that 
the  acidifying  organisms  are  usually  of  several  varieties  and  that 
the  milk  contains  a  variety  of  other  organisms  which  have  grown 
at  the  same  time,  many  of  which  are  undesirable.  It  is  far  wiser, 
therefore,  to  prepare  foods  for  babies  by  the  addition  of  pure  cul- 
tures of  lactic-acid-forming  organisms  to  pure  or  boiled  milk.  The 
danger  of  infection  by  other  organisms  is  thus  avoided.  The 
bacillus  Bulgaricus  is  the  one  perhaps  most  commonly  used.  It  is 
liable,  however,  to  make  the  taste  of  the  milk  too  acid.  Another 
organism,  perhaps  better,  is  the  bacillus  acidi  paralactici.  Cul- 
tures of  lactic-acid-forming  organisms  are  now  easily  obtainable 
from  milk  laboratories  and  chemists.  Better  results  are  usually 
obtained  by  the  use  of  a  "starter"  than  by  the  use  of  a  new  culture 
each  time.^  Cultures  are  much  preferable  to  the  various  lactic  acid 
tablets  on  the  market,  many  of  which  are  inert  and  none  of  which 
are  as  active  as  cultures.^ 

Protein  Milk  (Eiweissmilch,  Casein  Milk,  Albumin  Milk). — 
Finkelstein  and  Meyer  conclude  from  their  observations  that 
sugar  is  the  special  and  primary  cause  of  intestinal  fermentation 
and  that  the  fat  is  never  involved  primarily.  They  believe  that 
the  fermentation  of  the  sugar  is  dependent  on  two  main  factors: 
the  concentration  of  the  whey  and  the  relative  proportions  of 
casein  and  sugar  in  the  mixture.  They  conclude,  therefore,  that 
the  principles  on  which  the  preparation  of  a  food  to  combat  intes- 
tinal fermentation  depend  are:  a  diminution  in  the  quantity  of 
milk  sugar,  a  diminution  of  the  salts  through  dilution  of  the  whey, 
and  an  increase  in  the  casein,  with  varying,  and,  under  certain  cir- 
cumstances, not  inconsiderable  amounts  of  fat.  After  improve- 
ment has  begun,  an  easily  assimilable  and  consequently  Uttle 
fermentable  carbohydrate  should  be  added.  They  consequently 
developed  a  food  to  meet  these  indications  to  which  they  gave  the 
name  of  Eiweissmilch.  This  food  is  prepared  as  follows :  Heat  one 
quart  of  whole  milk  to  100"  F.  Add  four  teaspoonfuls  of  essence  of 
pepsin  and  stir.  Let  the  mixture  stand  at  100°  F.  until  the  curd  has 
formed.  Put  the  mass  in  a  Unen  cloth  and  strain  off  the  whey 
from  the  curd.  Remove  the  curd  from  the  linen  cloth  and  press  it 
through  a  rather  fine  sieve  two  or  three  times  by  the  means  of  a 
wooden  mallet  or  spoon.  Add  one  pint  of  water  to  the  curd  during 
this  process.     The  mixture  should  now  look  Uke  milk  and  the 

*  Morse  and  Bowditch:  Archives  of  Pediatrics,  1906,  xxiii,  889. 

*  Heinemann:  Jour.  Amer.  Med.  Ass'n,  1909,  lii,  372,  and  1912,  Iviii,  1252. 


PROTEIN  MILK  223 

precipitate  must  be  very  finely  divided.  Add  one  pint  of  butter- 
niilk  to  this  mixture. 

Finkelstein  and  Meyer  used  buttermilk  in  the  preparation  of 
this  food  for  the  following  reasons:  1,  because  of  the  small  amount 
of  milk  sugar  which  it  contains;  2,  to  obtain  the  good  effects  of  the 
lactic  acid,  and  3,  because  buttermilk  can  be  kept  for  a  long  time. 

The  composition  of  this  food  is: 

Fat : 2.5% 

Sugar 1.5% 

Protein 3.0% 

Salts 0.5% 

One  quart  of  this  milk  contains  about  370  calories. 

They  call  attention  to  the  low  caloric  value  of  this  food  and  to 
the  necessity  of  increasing  it  as  soon  as  possible  by  the  addition  of 
dextrin-maltose  mixtures. 

They  claim  that  it  is  worthy  of  employment  in  all  the  disturb- 
ances of  nutrition  in  infants  which  are  accompanied  by  diarrhea 
of  no  matter  what  sort  or  variety.  The  use  of  this  food  has  been 
extended  by  others  to  all  sorts  of  conditions,  including  the  feeding 
of  well  infants  and  the  newly-born,  and  good  results  claimed  for  it. 

The  principle  of  the  treatment  of  fermentative  conditions  caused 
by  sugar  with  a  food  low  in  sugar  and  salts  and  high  in  protein  is 
a  rational  one,  as  is  the  substitution  of  the  dextrin-maltose  mix- 
tures for  lactose.  It  hardly  seems  rational,  however,  to  believe 
that  all  disturbances  of  nutrition  accompanied  by  diarrhea  are 
due  to  the  same  cause  and  should  be  treated  in  the  same  way. 
Neither  does  it  appear  reasonable  to  think  that  any  method  of 
feeding  can  be  applicable  to  both  the  sick  and  the  well  or  to  give 
all  babies  the  same  food  without  regard  to  their  individual  digest- 
ive capacities. 

It  is  possible,  however,  to  take  advantage  of  the  main  principles 
of  this  method  of  treatment  of  the  intestinal  fermentative  condi- 
tions and  at  the  same  time  avoid  the  disadvantages  of  a  routine 
food  by  applying  them  in  the  modification  of  milk  by  the  percent- 
age method.  The  buttermilk  seems  to  be  an  unnecessary  addition, 
because  the  low  salt  and  high  casein  content,  which  form  the 
raison  d'etre  of  the  food,  can  be  obtained  perfectly  well  without  it. 
It  is  possible  by  the  use  of  cream  containing  a  high  percentage  of 
fat  to  reduce  the  amount  of  unprecipitated  casein  and  whey  protein 
to  a  very  small  percentage  and  yet  have  any  desired  percentage 
of  fat  in  the  mixture.  The  percentages  of  salt  and  sugar  are  also 
kept  low  because  of  the  small  amount  of  cream  required.    Any  per- 


224  PROTEIN  MILK 

centage  of  casein  desired  can  then  be  added  in  the  form  of  precip- 
itated casein  prepared  according  to  Finkelstein  and  Meyer's 
method.  The  advantages  of  this  method  of  treatment  of  ferment- 
ative intestinal  conditions  are  retained  in  this  way  and  the  dis- 
advantages of  a  routine  method  avoided.  The  dextrin-maltose 
mixtures  can  be  added,  of  course,  when  desired,  and  the  percent- 
age of  salt  increased  by  the  substitution  of  creams  containing 
lower  percentages  of  fat. 

The  preparation  of  protein  milk  and  of  modifications  of  milk 
made  with  precipitated  casein  is  a  difficult  matter  outside  of  milk 
laboratories  or  institutions.  This  method  of  treatment  is,  there- 
fore, hardly  applicable  in  the  home.  The  addition  of  dried,  pow- 
dered casein  and  paracasein  to  mixtures  made  in  the  ordinary  way, 
as  suggested  by  Bowditch  and  Bosworth  ^  offers  another  method 
of  combining  low  percentages  of  sugar  and  salts  with  a  high  per- 
centage of  casein.  This  method  is,  moreover,  much  simpler  and 
can  be  carried  out  in  the  home  as  well  as  in  institutions  or  milk 
laboratories. 

*  Amer.  Jour.  Diseases  of  Children,  1913,  vi,  394. 


CHAPTER  XVIII 
THE  PRESCRIBING  OF  MODIFIED  MILK 

The  first  thing  to  do  in  prescribing  modified  milk  for  an  infant 
is  to  determine  what  percentages  of  fat,  sugar,  protein  and  starch 
shall  be  in  the  mixture.  The  next  things  to  decide  are  whether  the 
sugar  shall  be  in  the  form  of  milk  sugar,  cane  sugar  or  one  of  the, 
dextrin-maltose  mixtures  and  whether  a  part  of  the  protein  shall 
be  given  in  the  form  of  whey  protein  or  not.  It  is  then  necessary 
to  determine  whether  an  alkali  shall  be  added  or  not  and,  if  it  is 
added,  what  form  shall  be  used  and  how  much  of  it.  Finally  it 
must  be  decided  whether  the  mixture  shall  be  given  raw,  pasteur- 
ized, and  if  so,  at  what  temperature,  or  boiled.  After  all  these 
points  are  settled,  the  number  of  feedings  and  the  amount  at  each 
feeding  must  be  decided,  bearing  in  mind  in  this  connection  that 
the  total  quantity  given  in  the  twenty-four  hours  is  far  more  im- 
portant than  the  number  of  feedings  and  the  size  of  the  individual 
feeding.  It  is  advisable,  after  deciding  upon  the  total  quantity, 
to  calculate  the  caloric  value  of  the  food  and  the  amount  of  protein 
which  it  contains  in  order  to  know  whether  the  caloric  and  protein 
needs  are  being  covered  or  greatly  exceeded.  In  most  instances 
the  food  decided  upon  should  be  given,  even  if  its  caloric  and  pro- 
tein content  do  not  correspond  to  the  established  standards.  The 
knowledge  of  these  points  will,  however,  often  prove  of  great  assist- 
ance in  changing  the  food  in  the  future,  if  the  baby  does  not  thrive 
on  it.  In  special  cases  it  is  also  necessary  to  determine  whether 
the  mixture  shall  be  acted  upon  by  lactic  acid  organisms  or  not, 
and,  if  so,  whether  or  not  they  shall  be  destroyed  by  heat;  in  others, 
whether  some  form  of  protein  milk  (Eiweissmilch)  shall  be  used  or 
the  milk  pancreatized. 

Every  one  of  these  points  must  be  decided  every  time  that  a 
modified  milk  mixture  is  prescribed.  No  single  one  of  them  can 
be  omitted.  They  must  be  decided,  moreover,  not  by  following 
blindly  the  rules  of  some  authority  on  infant  feeding  or  by  picking 
a  formula  from  a  table  in  some  text-book,  but  on  the  indications 
in  the  given  case  at  the  given  time. 

When  the  composition  and  the  amount  of  the  food  have  been 
decided,  the  food  may  be  prepared  either  at  a  milk  laboratory  or  in 

225 


226        THE  PRESCRIBING  OF  MODIFIED  MILK 

the  home.  When  the  milk  is  to  be  prepared  at  a  milk  laboratory, 
it  is  only  necessary  to  write  a  prescription  for  the  food,  embodying 
the  points  already  determined.  Most  milk  laboratories  have  a 
prescription  form  in  which  it  is  only  necessary  to  fill  in  the  blank 
spaces.  This  form,  while  a  convenience,  is  in  no  way  a  necessity. 
The  physician  who  is  competent  to  prescribe  modified  milk  mix- 
tures has  no  need  of  a  form.  On  page  227  is  a  copy  of  the  prescrip- 
tion form  furnished  by  the  milk  laboratories  in  the  neighborhood 
of  Boston. 

There  is  no  doubt  that  a  milk  laboratory  can  prepare  mixtures 
of  modified  milk  more  accurately  than  they  can  be  prepared  in  the 
home.  The  milk  and  cream  can  be  analyzed  daily  in  the  laboratory 
and  the  sugar  and  starch  accurately  weighed,  so  that  the  mixtures 
can  be  made  from  materials  of  known  composition.  This  cannot 
be  done  in  the  home.  Whether  the  formulae  are  actually  put 
up  more  accurately  in  the  laboratory  than  in  the  home  depends, 
however,  on  the  care  exercised  in  the  individual  laboratory  at  the 
given  time.  The  employees  in  milk  laboratories  are  human  and 
are,  therefore,  liable  to  be  careless  and  to  make  mistakes.  Another 
advantage  which  the  milk  laboratories  have  is  that  they  own  their 
own  farms  and  can,  therefore,  be  sure  of  having  a  clean  milk  from 
which  to  prepare  the  food.  The  individual  preparing  the  food  at 
home,  unless  able  to  procure  a  certified  milk,  can  never  be  sure 
whether  the  milk  is  clean  or  not. 

The  price  of  modified  milk,  prepared  at  milk  laboratories,  is  no 
higher  than  it  should  be,  when  the  character  of  the  materials  used, 
the  labor  required  in  the  modification  of  the  milk  and  the  cost  of 
deUvery  are  taken  into  consideration.  The  price  is,  nevertheless,, 
prohibitive  for  poor  people.  If  the  milk  has  to  be  sent  any  distance 
and  express  charges  added,  only  the  well-to-do  can  afford  to  have 
it.  Comparatively  few  babies  can  be  fed,  therefore,  on  modified 
milk  prepared  at  a  milk  laboratory.  The  vast  majority,  either 
because  of  the  expense  or  the  distance  from  a  laboratory,  must  be 
fed  on  mixtures  prepared  in  the  home. 

THE   HOME   MODIFICATION   OP  MILK 

Modifications  of  milk  for  infant  feeding  cannot  be  prepared  as 
accurately  in  the  home  as  at  a  milk  laboratory,  because  it  is  im- 
possible in  the  home  to  know  the  exact  composition  of  the  materials 
used  in  the  preparation  of  the  mixtures.  If  reasonable  care  is  used 
in  their  preparation,  however,  the  inaccuracies  are  not  as  great  as 
would  be  supposed.     In  fact,  in  the  vast  majority  of  instances, 


R 

Fats. 


THE  PRESCRIBING  OF  MODIFIED  MILK        227 

Per  Cent. 


Lactose  (Milk  Sugar) 

Maltose  (Malt  Sugar) 

Sucrose  (Cane  Sugar) 

Dextrose  (Grape  Sugar) 

Starch 


(a)  Carbohydrates 

(b)  Dextrinize 

f  Whev 
(c)Proteid3J  Casein. 

(d)  Peptonize 

(e)  Sodium  Citrate 

/t\  o  J-       r»-      u    f  %  of  milk  and  cream 

(f)  Sodium  Bicarb.  |  ^^  ^j  ^^^  ^^^^ 

%  of  milk  and  cream 
%  of  total  mixture 

1  To  inhibit  the  saprophytes  of  fer- 
mentation 

2  To  facilitate  digestion  of  the  pro- 
teids 


I  %  of  milk  and  cream 
\  %  of  total  mixture 


(g)  Lime  Water  • 


(h)  Lactic  Acid 
Bacillus 


Heat  at- 


Nimiber  of  Feedings  

Amount  at  each  Feeding 


ORDERED  FOR 


ADDRESS- 
DATE 


-19 


-M.  D. 


EXPLANATORY 


(a)  It  requires  0.75%  starch  to  make 
the  precipitated  casein  finer. 

(b)  One  hour  completely  dextrinizes 
the  Starch. 

(c)  In  case  physicians  do  not  wish  to 
Bub-divide  the  proteids,  the  words 
"Whey"  and  "Casein"  may  be  erased. 

(d)  Twenty  minutes  renders  the  mix- 
ture decidedly  bitter. 

(e)  It  requires  0.20%  of  the  milk  and 
cream  used  in  modifying  to  facilitate 
the  digestion  of  the  proteids;  i.  e.,  the 
formation  of  a  soft  curd.  0.40%  to  pre- 
vent the  action  of  rennet;  i.  c,  the 
formation  of  tough  curd. 

(0  It  requires  0.68%  of  the  milk  and 
cream  used  in  modifying  to  favor  the 
digestion  of  the  proteids.  1.70%  of  the 
amount  of  milk  and  cream  used  sus- 
pends all  action  on  the  proteids  in  the 
stomach.  0.17%  of  the  total  mixture 
gives  a  mild  alkaline  food. 


(g)  It  requires  20%  of  the  milk  and 
cream  used  in  modifying  to  favor  the 
digestion  of  the  proteids.  50%  of  the 
amount  of  milk  and  cream  used  sus- 
pends all  action  on  the  proteids  in  the 
stomach.  5%  of  the  total  mixture  gives 
a  mild  alkaline  food. 

(h)  Percentage  figures  represent  the 
per  cent  of  Lactic  Acid  attained  when 
the  food  is  removed  from  the  thermo- 
stat. When  the  Lactic  Acid  Bacillus  is 
used  to  facilitate  digestion  of  the  pro- 
teids, this  is  the  final  acidity,  as  the 
process  is  stopped  by  heat  at  this  point. 
When  the  Lactic  Acid  Bacillus  is  used 
to  inhibit  the  growth  of  saprophytes, 
the  acidity  may  subsequently  increase  to 
a  variable  degree,  as  the  bacilli  are  left 
alive.  0.25%  Lactic  Acid  just  curdles 
milk.  0.50%  gives  thick  curdled  milk. 
0.75%  separates  into  curds  and  whey. 


228        THE  PRESCRIBING  OF  MODIFIED  MILK 

they  are  not  great  enough  to  disturb  the  digestion  or  to  interfere 
with  the  nutrition  and  development  of  babies  fed  upon  them. 
The  average  infant  fortunately  does  not  notice  small  variations  in 
the  composition  of  an  artificial  food  any  more  than  it  does  similar 
variations  in  the  composition  of  breast-milk.  Extreme  accuracy 
is  necessary  only  in  exceptional  cases.  In  general,  therefore,  the 
modifications  of  milk  prepared  at  home  are  sufficiently  accurate 
for  all  practical  purposes  and  it  is  rarely  necessary  on  this  account 
to  have  recourse  to  a  milk  laboratory.  When  practicable,  it  is, 
however,  much  easier,  and  in  most  instances  will  be  found  more 
satisfactory,  to  have  modified  milk  prepared  at  a  laboratory 
rather  than  at  home. 

It  is  often  said  that  the  calculation  of  the  formulae  for  the  prej>- 
aration  of  modified  milk  at  home  is  too  complicated  for  the  average 
physician  to  carry  out  and  that  it  requires  more  time  than  the  busy 
practitioner  can  give  to  it.  These  statements  are  distinctly  not 
true.  There  is  nothing  about  the  calculation  of  formulae  suffi- 
ciently accurate  for  practical  purposes  which  cannot  be  understood 
by  anyone  with  even  an  elementary  knowledge  of  arithmetic. 
If  a  physician  cannot  understand  the  principles  involved,  there 
must  have  been  some  mistake  made  when  his  degree  was  granted. 
There  is  no  more  reason  why  a  physician  should  not  take  the  time 
to  calculate  a  proper  modification  of  milk  for  a  baby  than  why  he 
should  not  take  the  time  to  sterilize  his  hands  before  an  abdominal 
operation.  He  is  equally  negligent  in  either  case,  if  he  does  not. 
As  a  matter  of  fact,  however,  it  requires  but  little  time  to  calculate 
a  formula,  if  the  physician  knows  how  to  do  it.  Five  or,  at  the 
most,  ten  minutes  are  amply  sufficient. 

It  is  also  not  infrequently  said  that  the  procedures  involved  in 
the  preparation  of  modifications  of  milk  in  the  home  are  too  compli- 
cated for  the  ordinary  mother  or  nurse  maid  to  comprehend  and 
carry  out.  This  statement  is  also  untrue.  There  is  nothing  about 
the  preparation  of  modified  milk  in  the  home  which  any  woman 
of  average  intelligence  cannot  understand  and  do,  provided  it  is 
properly  explained  to  her.  The  trouble  is  not  with  the  women,  but 
with  the  physicians  who,  either  through  ignorance  or  carelessness, 
neglect  to  explain  the  details  of  the  preparation  of  the  food  to  them. 

In  prescribing  for  modified  milk  to  be  prepared  in  the  home  it  is 
necessary  to  determine  not  only  what  food  shall  be  given  to  the 
baby,  but  also  how  this  food  shall  be  prepared.  It  is  of  great 
importance,  in  the  first  place,  to  be  sure  that  the  milk  which  is  to 
be  used  is  a  clean  milk.  It  is  impossible  to  make  a  good  food  from 
dirty  milk,  no  matter  how  much  it  is  modified. 


THE  PRESCRIBING  OF  MODIFIED  MILK         229 

It  is  also  of  considerable  importance  to  employ  milk  which  is 
reasonably  constant  in  its  composition.  This  is  best  done  by  using 
certified  milk.  Modifications  prepared  from  ordinary  milk,  pro- 
vided it  is  not  from  Jersey  cows  or  similar  breeds,  are,  however,  in 
most  instances  sufiiciently  accurate  in  places  where  there  is  a 
legal  standard  for  milk.  When  there  is  a  doubt  as  to  the  composi- 
tion of  the  milk,  it  is  not  a  difficult  matter  to  determine  it  approx- 
imately. 

The  fat  content  of  milk  can  be  accurately  determined  in  a  few 
minutes  with  one  of  the  small  hand  Babcock  milk  testers.  A  very 
satisfactory  two-bottle  machine.  The  "Facile  Jr.,"  is  made  by 
D.  H.  Burrell  and  Co.,  of  Little  Falls,  N.  Y.  The  price  with 
bottles,  pipette  and  measuring  glasses  is  $4.50.  It  is  important  in 
making  this  test  to  use  sulphuric  acid  of  a  specific  gravity  of  from 
1.82  to  1.83  at  60°  F.  The  total  sohds  can  be  easily  determined  in 
a  few  minutes  with  a  lactothermometer  and  a  Richmond  "Milk 
SUde  Rule. "  These,  with  directions  for  their  use,  may  also  be  pro- 
cured of  D.  H.  Burrell  and  Co.,  the  price  of  the  lactothermometer 
being  from  $1.00  to  $1.50,  and  that  of  the  Richmond  "rule"  $2.50. 
The  percentage  of  fat  and  the  total  solids  being  known  and  the 
percentages  of  the  ash  and  sugar  being  fairly  constant,  the  per- 
centage of  the  protein  can  be  approximately  determined  with  rea- 
sonable accuracy  by  subtracting  the  sum  of  the  percentage  of  fat 
and  the  estimated  percentages  of  the  sugar  and  ash  from  the  per- 
centage of  the  total  solids.  The  percentage  of  casein  can  be  readily 
determined  in  from  fifteen  to  twenty  minutes  by  the  volumetric 
method  of  Van  Slyke  and  Bosworth,  if  more  accurate  results 
are  desired.^  Multiplying  the  percentage  of  casein  by  1.4  gives 
the  percentage  of  the  total  protein  accurately  enough  for  practical 
purposes. 

Composition  of  Materials  used  in  the  Home  Modification  of 
Milk. — It  being  impossible,  except  in  rare  instances,  to  analyze  the 
milk  and  cream  used  in  the  preparation  of  modified  milk  in  the 
home,  it  is  necessary  to  adopt  certain  arbitrary  standards  as  to  the 
composition  of  these  substances.  It  must  be  remembered  that  any 
form  of  milk  containing  more  than  4%  of  fat  is  technically  cream. 
It  is  wrong,  therefore,  to  think  and  speak  of  cream  as  a  definite 
entity,  without  qualification.  It  is  more  correct  to  think  of  creams, 
with  the  fat  content  always  specified.  The  following  figures 
(Table  43)  as  to  the  composition  of  the  various  creams,  whole 
milk,  skimmed  milk  and  whey  are  approximately  correct: 

» New  York  Medical  Journal,  1909,  xc,  542. 


230 


THE  PRESCRIBING  OF  MODIFIED  MILK 


TABLE  43 


Whole  milk 

7%  cream 

10%  cream 

16%  cream 

32%  cream 

Skimmed  milk 

Separated  milk  ("fat  free") 
Whey 


Fai 


4.00 

7.00 

10.00 

16.00 

32.00 

1.00 

0.25 

0.25 


MUk  sugar 


4.50 
4.45 
4.40 


20 
40 
00 
00 
00 


Protein 


3.50 
3.40 
3.25 
3.05 
2.50 
3.55 
3.65 
0.90 


If  milk  is  allowed  to  set  six  hours  or  longer,  the  upper  sixteen 
ounces  of  a  quart  of  bottled  milk  contain  7%  and  the  upper  ten 
ounces  10%  of  fat.  The  cream  layer,  that  is  "gravity  cream," 
without  regard  to  how  many  ounces  of  it  there  are  on  a  quart, 
contains  about  16%  of  fat.  If  the  whole  milk  from  which  cream  is 
obtained  contains  more  than  4%  of  fat,  the  cream  will  contain  a 
proportionally  larger  amount.  Ordinary  "thick  cream,"  as  it  is 
called,  contains,  on  the  average,  32%  of  fat.  The  composition  of 
this  type  of  cream  is,  however,  very  variable,  so  variable  indeed 
that  it  is  hardly  safe  to  use  it  in  the  preparation  of  modified  milk, 
unless  the  percentage  of  fat  is  known. 

Skimmed  milk  is  the  milk  which  is  left  after  the  gravity  cream 
has  been  removed  by  a  dipper  or  by  pouring.  If  some  of  the  upper 
layers  of  the  milk  are  removed  in  addition  to  the  cream,  the  part 
which  is  left  contains  less  than  1%  of  fat.  Separated  ("fat  free") 
milk  is  the  milk  which  is  left  when  the  cream  has  been  removed  by 
centrifugalization.  The  whey  obtained  from  separated  milk  con- 
tains 1%  of  protein. 

Table  44  copied  from  Chapin  and  Pisek,^  shows  the  percentage 
of  fat  in  each  of  the  top  nine  ounces  of  a  quart  of  bottled  milk 
which  has  set  six  hours  or  longer,  and  the  fat  content  of  the 
top  ounces,  from  two  ounces  to  thirty  ounces,  under  the  same 
conditions. 

It  is  evident  that  "top  milk"  may  mean  any  number  of  ounces, 
from  one  to  thirty-one  ounces,  from  a  quart.  It  is  also  evident  that 
the  so-called  "top  milks"  are  merely  creams  of  varying  per- 
centages and  that  modifications  of  milk  made  from  "top  milks" 
differ  in  no  way  from  those  made  from  creams  except  in  name. 
Since  top  milks  vary  as  much  in  their  fat  contents  as  do  creams,  it  is 
evidently  just  as  important  in  prescribing  for  the  preparation  of 


'  Diseases  of  Children,  1909,  p.  138. 


THE  PRESCRIBING  OF  MODIFIED  MILK        231 


TABLE  44 
First  ounce  contains 25.0%  fat 


2  ounces  mixed  contain 24.0%  fat 


Second    ' 

Third      ' 

Fourth    ' 

Fifth       ' 

Sixth       ' 

Seventh  ' 

Eighth    ' 

Ninth     ' 

Top    2oi 

iinces 

mixe 

3 

4 

5 

6 

7 

8 

9 

10 

12 

14 

16 

18 

20 

22 

24 

26 

28 

30 

.23.0% 
.19.0% 

.18.5% 
.10.5% 
.  4.8% 
.  3.4% 
.  2.2% 
.   1.8% 


.22.5% 
.21.4% 
.19.2% 
.16.8% 
.15.0% 
.13.3% 
.11.5% 
.10.5% 
.  9.0% 
.  7.8% 
.  7.0% 
.  6.3% 
.  5.8% 
.  5.4% 
.  5.0% 
.  4.7% 
.  4.5% 
.  4.3% 


modified  milk  at  home  to  specify  exactly  what  top  milk  is  to  be 
used  as  it  is  to  specify  what  sort  of  cream  is  to  be  used. 

Method  of  Calculation  of  Formulae  for  the  Home  Modification 
of  Milk. — There  are  many  methods  for  the  calculation  of  the 
formulae  for  modifications  of  milk  to  be  prepared  in  the  home. 
Most  of  them  are  inaccurate  in  that  the  fat  in  the  skimmed  milk  is 
disregarded,  many  of  them  in  that  the  percentage  of  protein  in  the 
cream  and  skimmed  milk  is  considered  to  be  the  same.  All  of  them 
are  accurate  enough,  however,  for  everyday  work.  It  makes  but 
little  difference  which  method  is  employed,  provided  that  method 
is  understood  and  used  correctly.  It  makes  no  difference  whether 
gravity  cream,  10%  cream,  top  milks,  skimmed  milk  or  whole 
milk  are  used  in  the  preparation  of  the  mixtures.  Equally  good 
results  can  be  obtained  with  all.  The  one  important  thing  is  that 
the  food  be  calculated  in  percentages  of  the  various  food  elements. 
It  makes  little  difference  how  these  elements  are  obtained.  Meth- 
ods which  take  the  fat  in  the  skimmed  milk  and  the  differences  in 


232        THE  PRESCRIBING  OF  MODIFIED  MILK 

the  protein  content  of  the  various  creams  and  milks  into  account 
are  too  comphcated  for  ordinary,  cUnical  use  and  are,  fortunately, 
unnecessary.  Those  who  wish  to  familiarize  themselves  with 
these  different  methods  can  find  them  fully  described  in  two 
articles  by  Westcott.^ 

The  writers  have  found  the  following  method  of  calculation  a 
satisfactory  one  in  their  own  practice  and  have  found  that  medical 
students  understand  it  quickly  and  apply  it  easily  and  these  are  its 
chief  recommendations.  It  is  unquestionably  inaccurate  in  many 
ways,  as  are  all  simple  methods  of  calculation.  It  must  be  remem- 
bered, however,  in  criticising  methpds  of  calculation  for  their 
inaccuracies,  that,  if  the  same  method  is  used  consistently,  the 
inaccuracies  are  always  similar  and  that  different  modifications  of 
milk  prepared  by  the  same  method  are  accurate  relatively  to  each 
other.  That  is  to  say,  if  a  baby  who  is  taking  a  mixture  supposed 
to  contain  3.50%  of  fat,  but  which  really  contains  4%  of  fat, 
shows  symptoms  of  fat  indigestion,  a  reduction  of  0,50%  in  the 
percentage  of  fat  will  have  the  same  effect  in  relieving  these 
symptoms,  although  it  is  a  reduction  from  4%  to  3.50%  instead  of 
one  from  3.50%  to  3%,  as  it  is  supposed  to  be.  That  is,  changes  in 
the  percentages  are  correct,  even  if  the  original  percentages  are 
incorrect. 

Gravity  cream  and  skimmed  milk  are  used  in  this  method.  The 
gravity  cream  is  estimated  to  contain  16%  of  fat  and  the  skimmed 
milk  to  be  fat  free.  The  mixtures,  therefore,  all  contain  a  some- 
what higher  percentage  of  fat  than  they  are  supposed  to  contain. 
The  protein  content  of  both  the  gravity  cream  and  the  skimmed 
milk  is  calculated  to  be  3.20%.  This  percentage  is  higher  than 
that  really  present  in  the  cream  and  lower  than  that  in  the 
skimmed  milk.  Numerous  analyes,  made  by  us  by  the  Kjeldahl 
method,  of  the  protein  content  of  mixtures  prepared  in  this  way 
have  shown,  however,  that  the  percentage  of  protein  in  them  is 
not  far  from  what  it  is  calculated  to  be.  They  are  much  more 
nearly  correct  than  would  be  expected.  The  percentage  of  sugar 
is  estimated  at  4.50  in  both  the  gravity  cream  and  skimmed 
milk. 

It  may  be  well  to  define  what  is  meant  by  gravity  cream  and 
skimmed  milk  once  more  before  describing  the  method  of  calcula- 
tion.   By  gravity  cream  is  meant  all  the  cream  which  is  visible  on 

1  The  Scientific  Modification  of  Milk.  International  Clinics,  1900,  Tenth 
Series,  iii,  233,  and  A  Method  for  the  Differential  Modification  of  the  Proteids 
in  Percentage  Milk  Mixtures.  American  Journal  Medical  Sciences,  1901, 
cxxii,  439. 


THE  PRESCRIBING  OF  MODIFIED  MILK 


233 


milk  which  has  set  for  six  hours  or  longer.  All  the  cream  must  be 
removed  and  the  required  nimiber  of  ounces  taken  from  it.  If 
there  is  not  enough  cream  on  one  bottle,  the  cream  must  be  re- 
moved from  two  bottles  and  mixed.  The  required  number  of 
ounces  is  then  taken  from  the  mixture  of  the  two.  The  cream  may 
be  removed  with  a  cream  dipper  or  it  may  be  poured  off.  The 
results  obtained  by  pouring  are  not  as  accurate  as  those  obtained 
by  dipping.  The  same  result  may  be  obtained  by  siphoning  off 
the  milk  below  the  cream  and  leaving  the  cream  in  the  bottle. 
When  a  cream  dipper  is  used,  the  first  ounce  must,  of  course,  be 
removed  with  a  spoon  or  the  milk  will  be  spilled  when  the  dipper  is 
introduced.  Most  bottled  milk  has  been  in  the  bottles  many  more 
than  six  hours  before  it  is  delivered.  When  the  milk  bottle  is 
full,  the  cream  rises  even  during  transportation.  It  is  not  neces- 
sary, therefore,  to  wait  six  hours  after  the  milk  is  delivered  before 
preparing  the  food,  provided  the  cream  line  is  distinct. 

By  skimmed  milk  is  meant  what  is  left  after  the  gravity  cream 
has  been  removed.  The  percentage  of  fat  in  the  mixture  will  be 
more  nearly  correct  if  the  lowest  ounces  are  used  instead  of  the 
same  number  of  ounces  from  the  whole  of  the  skimmed  milk. 

A  rounded  tablespoonful  of  milk  sugar  is  considered  in  this 
method  of  calculation  to  weigh  one-half  an  ounce.  It  will  be 
found  that  this  is  not  far  from  the  true  weight.  By  a  rounded 
tablespoonful  is  meant  what  is  contained  in  a  tablespoon  when 
it  is  dipped  into  milk  sugar  and  then  gently  shaken,  that  is,  it  is 
rounded,  not  heaped  or  level.  Every  cook  knows  what  is  meant  by 
this  term.  The  weight  of  equal  quantities  of  milk  sugar  and  the 
dextrin-maltose  mixtures  is  nearly  enough  the  same  for  practical 
purposes. 

The  estimated  composition  of  the  materials  used  in  the  prepara- 
tion of  the  mixtures  is,  therefore,  as  follows : 


TABLE  45 


Fat 


Milk  sugar 


Protein 


Gravity  cream 
Skimmed  milk 
Milk  sugar. . . 


16.00% 
0.00% 


4.50% 
4.50% 


1  rounded  tablespoonful  =  3^  ounce. 


3.20% 
3.20% 


It  is  necessary,  as  always,  before  beginning  the  calculations  as  to 
the  preparation  of  the  food,  to  decide  what  percentages  of  fat, 
sugar  and  protein  the  food  is  to  contain,  how  much  is  to  be  given 
in  the  twenty-four  hours  and  how  much  lime  water,  if  any,  is  to 


234        THE  PRESCRIBING  OF  MODIFIED  MILK 

be  added.  It  is  usually  advisable  to  make  the  quantity  large 
enough  to  allow  for  an  extra  bottle,  so  that,  if  a  bottle  is  broken, 
the  baby  need  not  go  hungry. 

Suppose  that  it  is  desired  to  prepare  thirty-two  ounces  of  a  mix- 
ture containing  3%  of  fat,  6%  of  milk  sugar  and  2%  of  protein, 
with  lime  water  enough  to  equal  25%  of  the  milk  and  cream  in  the 
mixture.  The  fat  in  the  food  must  be  derived  from  the  cream, 
because  it  is  the  only  substance  containing  fat  to  be  used  in  the 
preparation  of  the  food.  If  the  food  was  composed  entirely  of 
gravity  cream  it  would  contain  16%  of  fat.  Since  it  is  to  contain 
but  3%  of  fat,  it  is  evident  that  only  three-sixteenths  of  the  mix- 
ture must  be  gravity  cream.  Ye  of  thirty-two  ounces  is  six  ounces. 
Six  ounces  of  gravity  cream  will,  therefore,  provide  the  3%  of  fat 
desired  in  the  mixture. 

The  gravity  creain  contains  protein  as  well  as  fat.  There  are 
six  ounces  of  gravity  cream  in  the  thirty-two-ounce  mixture.  The 
protein  content  of  gravity  cream  is  3.20%.  The  protein  content  of 
a  thirty-two-ounce  mixture  containing  six  ounces  of  gravity  cream 
is  evidently  ^2^  of  3.20%,  or  0.60%.  Two  per  cent  of  protein  is, 
however,  desired  in  the  mixture.  The  gravity  cream  has  provided 
only  0.60%.  One  and  forty  hundredths  per  cent  of  protein,  the 
difference  between  the  percentage  of  protein  desired  and  that  fur- 
nished by  the  gravity  cream,  must  be  obtained  in  some  other  way. 
It  must  be  obtained,  moreover,  from  some  substance  which  does 
not  contain  fat.  Skimmed  milk  is  such  a  substance.  Skimmed 
milk  contains  3.20%  of  protein.  In  order  to  get  1.40%  of  protein 
in  the  mixture  by  the  use  of  skimmed  milk,  it  is  evident  that 
^  1^  of  the  mixture  must  be  skimmed  milk.  ^|^  of  thirty-two 
ounces  is  fourteen  ounces.  Fourteen  ounces  of  skimmed  milk  will, 
therefore,  provide  the  additional  1.40%  of  protein  desired. 

Both  gravity  cream  and  skimmed  milk  contain  4.50%  of  milk 
sugar.  Twenty  ounces  of  gravity  cream  and  skimmed  milk  are 
required  to  furnish  the  desired  percentages  of  fat  and  protein. 
These  twenty  ounces  in  a  thirty-two-ounce  mixture  must  add  ^^ 
of  4.50%  of  sugar  to  the  mixture.  Twenty  thirty-seconds  of  43^,  or 
If  of  |  =  -Vrj  or  practically  3%  of  milk  sugar.  It  is,  however, 
desired  to  have  6%  of  milk  sugar  in  the  mixture.  That  is,  3%  more 
of  milk  sugar  is  required.  This  additional  sugar  must  be  added  in 
the  form  of  dry  milk  sugar.  Three  per  cent  of  thirty-two  ounces  is 
Y^  of  thirty-two.  This  will  give  the  amount  of  sugar  desired  in 
ounces.  The  sugar  is  to  be  measured  in  rounded  tablespoonfuls, 
or  half  ounces.  If  the  figures  given  above  are  multiplied  by  two, 
the  result  will  be  the  number  of  rounded  tablespoonfuls  needed. 


THE  PRESCRIBING  OF  MODIFIED  MILK         235 


That  is,  y '  ff  of  32  X  2  =  If  grounded  tablespoonfuls,  or  for  all  prac- 
tical purposes,  two  rounded  tablespoonfuls. 

It  is  also  desired  to  have  an  amount  of  lime  water  in  the  mixture 
equal  to  25%  of  the  cream  and  milk  in  the  mixture.  There  are 
twenty  ounces  of  cream  and  milk  in  the  mixture.  Twenty-five  per 
cent  of  twenty  ounces  is  five  ounces.  Five  ounces  of  lime  water 
must,  therefore,  be  added.  The  total  quantity  of  the  mixture  is  to 
be  thirty-two  ounces.  The  mixture  is  to  contain  six  ounces  of  grav- 
ity cream,  fourteen  ounces  of  skimmed  milk  and  five  ounces  of  lime 
water,  that  is,  twenty-five  ounces.  The  milk  sugar  goes  into  solu- 
tion and,  therefore,  does  not  add  to  this  quantity.  The  difference 
between  thirtj'^-two  ounces  and  twenty-five  ounces  is  seven  ounces. 
Seven  ounces  of  water  must,  therefore,  be  added  to  make  up  the 
quantit}"^  desired.  The  following  table  shows  the  results  of  the 
steps  just  described: 


TABLE 

46 

Ounces 

Fat 

Sugar 

Protein 

Gravity  cream 

Skimmed  milk 

Milk  sugar 

Lime  water 

6 
14 

2  rounded  table- 
spoonfuls 
5 

7 

3.00 

3.00 
3.00 

0.60 
1.40 

Water 

32 

3.00 

6.00 

2.00 

The  nailk  sugar  should  be  dissolved  in  the  seven  ounces  of  hot 
water.  The  water  should  be  allowed  to  cool  and  then  be  mixed 
with  the  other  ingredients. 

Mixtures  containing  Starch. — It  is  as  important  to  have  the  per- 
centage of  starch  in  the  food  accurate  as  it  is  to  have  those  of  the 
fat,  sugar  and  protein.  Starch  is  usually  added  in  the  form  of  the 
cereal  waters.  The  strength  of  the  cereal  water  which  is  to  be  used 
in  the  preparation  of  the  food  must  be  known,  therefore,  in  order 
to  get  the  desired  percentage  of  starch  in  the  mixture. 

Two  rounded  teaspoonfuls  of  barley  or  oat  flour  to  the  pint  of 
water  have  been  found  by  analysis  to  give  a  1.50%  decoction  of 
starch,  while  four  rounded  teaspoonfuls  to  the  pint  of  water  give  a 
3%  decoction.  The  flour  should  be  mixed  with  a  small  amount  of 
water,  after  which  the  remainder  of  the  water  is  added.  The  mix- 
ture is  then  boiled  for  twenty  minutes,  after  which,  as  some  of  the 
water  has  boiled  away,  enough  hot  water  is  added  to  make  up  the 


236         THE  PRESCRIBING  OF  MODIFIED  MILK 

original  pint.  It  should  then  be  strained  through  several  thick- 
nesses of  cheesecloth.  It  should  be  cooled  before  being  mixed  with 
the  milk  and  cream. 

If  it  is  desired  to  have  0.75%  of  starch  in  a  mixture  and  a  cereal 
water  containing  1.50%  of  starch  is  to  be  used,  it  is  evident  that 
one-half  of  the  mixture  must  be  made  up  of  the  cereal  water.  If  a 
3%  cereal  water  is  used,  one-quarter  of  the  mixture  will  be  re- 
quired to  give  0.75%  of  starch.  Suppose  that  it  is  desired  to  have 
0.75%  of  barley  starch  in  the  mixture  which  has  just  been  calcu- 
lated. In  order  to  get  0.75%  of  starch  in  a  thirty-two-ounce  mix- 
ture, using  1.50%  barley  water,  it  will  be  necessary  to  use  x'M  of 
thirty-two  ounces,  or  sixteen  ounces.  The  mixture  already  con- 
tains twenty-five  ounces  of  gravity  cream,  skimmed  milk  and  lime 
water,  leaving  room  for  only  seven  ounces  of  barley  water.  It  is 
plain,  therefore,  that  it  is  impossible  to  have  0.75%  of  starch  in  the 
mixture,  if  1.50%  barley  water  is  used.  If  3.00%  barley  water  is 
used,  ^:J^  of  thirty-two  ounces,  or  eight  ounces  will  be  required. 
There  is  room  for  only  seven  ounces.  The  difference  in  the  per- 
centage of  starch  added  when  seven  or  eight  ounces  are  added  is 
only  0.10%,  which  is  a  negligible  amount.  Seven  ounces  of  3.00% 
barley  water  will,  therefore,  be  sufficient. 

If  preferred,  the  amount  of  starch  to  be  added  to  a  mixture  to 
give  any  percentage  required  of  starch  in  the  mixture  may  be  cal- 
culated directly.  Suppose,  for  example,  it  is  desired  to  have  0.75% 
of  barley  starch  in  a  forty-eight-ounce  mixture.  Two  rounded 
teaspoonfuls  of  barley  flour  to  the  pint  gives  1.50%  of  starch  in 
the  mixture.  One  rounded  teaspoonful  to  the  pint  gives  0.75% 
of  starch  in  the  mixture.  There  are  three  pints  in  forty-eight 
ounces.  Therefore  three  rounded  teaspoonfuls  of  flour  will  be  re- 
quired to  give  0.75%  of  starch  in  forty-eight  ounces.  This  amount 
of  barley  flour  should  be  cooked  in  the  number  of  ounces  of  water 
in  the  mixture  and  then  mixed  with  the  gravity  cream  and  skimmed 
milk. 

Whey  Mixtures. — It  is  impossible  to  make  mixtures  containing 
a  high  percentage  of  whey  protein  with  a  low  percentage  of  casein, 
provided  they  contain  more  than  1  or  2%  of  fat,  if  gravity  cream 
is  used  in  the  preparation  of  the  food,  as  it  usually  is  in  the  home. 
The  reason  of  this  is  that  the  gravity  cream  which  it  is  necessary 
to  use  in  order  to  get  the  desired  percentages  of  fat  contains  a  con- 
siderable amount  of  protein  and  by  its  bulk  diminishes  the  amount 
of  whey  and  consequently  the  amount  of  whey  protein  which  can 
be  added.  It  is  usually  desired,  when  whey  protein  is  prescribed, 
to  have  as  much  of  it  in  a  mixture  as  is  possible.    For  practical  pur- 


THE  PRESCRIBING  OF  MODIFIED  MILK        237 

poses,  therefore,  when  whey  mixtures  are  prepared  in  the  home 
with  gravity  cream,  the  amount  of  gravity  cream  required  to  give 
the  desired  percentage  of  fat  is  calculated  and  the  rest  of  the  mix- 
ture made  up  with  whey,  the  amount  of  whey  protein  added  being 
determined  later.  Smaller  percentages  of  whey  protein  can  be 
added,  of  course,  if  desired. 

Suppose  that  it  is  desired  to  give  a  baby  a  twenty-four-ounce 
mixture  containing  3%  of  fat  and  6%  of  sugar,  with  lime  water 
10%  of  the  cream  in  the  mixture.  -^  of  twenty-four  ounces  is  four 
and  one-half  ounces.  Four  and  one-half  ounces  of  gravity  cream 
will,  therefore,  be  requu-ed.  This  will  put  ^^V-  of  3.20%,  or  0.60%, 
of  protein  in  the  mixture.  This  protein  is  chiefly  in  the  form  of  ca- 
sein. Ten  per  cent  of  four  and  one-half  ounces  is  nearly  one-half  an 
ounce.  One-half  an  ounce  of  lime  water  must,  therefore,  be  added. 
It  is  evident  that  there  is  room  for  nineteen  ounces  of  whey  in  the 
mixture,  the  difference  between  twenty-four  and  4)^  -\-  ]/2,  being 
nineteen.  The  composition  of  whey  for  practical  work  in  the  home 
modification  of  milk  may  be  calculated  to  be  0.90%.  ||  of  0.90% 
of  whey  protein  gives  0.70  of  whey  protein,  which  is  the  amount 
added  by  the  whey. 


Fat 

MUk  sugar 

Whey  protein 

Whey 

0.00 

4.50 

0.90 

Both  the  gravity  cream  and  the  whey  contain  4.50%  of  milk 
sugar.  There  being  but  one-half  ounce  of  lime  water  in  the  whole 
mixture,  it  already  contains  approximately  4.50%  of  milk  sugar. 
It  being  desired  to  have  6%  of  milk  sugar  in  the  mixture,  1.50% 
more  must  be  added  in  the  form  of  dry  milk  sugar,  -xvir  of 
24  X  2  =  0.72  of  a  rouriHed  tablespoonful.  A  level  tablespoonful 
of  milk  sugar  will,  therefore,  just  about  make  up  the  required 
percentage  of  sugar. 

The  mixture  contains  3%  of  fat,  6%  of  sugar,  0.70%  of  whey 
protein  and  0.60%  of  casein.  It  is  evident,  therefore,  that,  if  grav- 
ity cream  is  used,  it  is  impossible  to  get  less  than  0.60%  of  casein 
in  the  mixture  with  3%  of  fat,  or  less  than  0.80  of  casein  with  4%  of 
fat.  The  percentage  of  whey  protein  in  the  mixture  is  really  some- 
what higher  and  that  of  the  casein  somewhat  lower  than  has  been 
calculated,  because  about  one-quarter  of  the  protein  furnished  by 
the  cream  is  in  the  form  of  whey  protein.  It  is  not  necessary  for 
every-day  work,  however,  to  take  these  small  differences  into  con- 
sideration. 


238        THE  PRESCRIBING  OF  MODIFIED  MILK 

Higher  percentages  of  whey  protein  and  lower  percentages  of 
casein  can  be  obtained  with  given  percentages  of  fat,  if  creams 
containing  higher  percentages  of  fat  are  used.  It  is  possible,  for 
example,  even  in  the  home,  to  get  cream  containing  24%  of  fat  by 
taking  only  the  top  two  ounces  off  of  the  quart. 

It  is  also  possible  to  have  any  percentage  of  casein  desired  with  a 
given  percentage  of  fat  by  using  skimmed  milk  in  the  mixture.  The 
amount  of  whey  protein  which  can  be  put  in  the  mixture  is,  of 
course,  correspondingly  diminished.  When  it  is  desired  to  work 
off  of  a  whey  mixture  on  to  an  ordinary  mixture  without  in- 
creasing the  total  amount  of  protein,  it  is  best  done  by  gradually 
replacing  the  whey  by  skimmed  milk  and  water.  One  ounce  of 
skinamed  milk  and  three  ounces  of  water  contain  approximately 
the  same  amount  of  protein  as  four  ounces  of  whey. 

Preparation  of  Whey. — Put  a  pint  of  skimmed  milk  into  a  clean 
saucepan  and  heat  it  until  it  is  lukewarm  (not  over  100°  F.).  Take 
off  of  the  stove.  Add  two  teaspoonfuls  of  essence  of  pepsin  or  liq- 
uid rennet,  or  two  junket  tablets.  Stir  just  enough  to  mix.  Let 
it  stand  until  firmly  jellied.  Then  break  up  with  a  fork  until  it  is 
finely  divided.  Strain  through  a  linen  cloth  or  several  thicknesses 
of  cheesecloth.  What  goes  through  is  whey.  If  whey  is  to  be  mixed 
with  cream,  milk  or  skinuned  milk,  it  must  be  brought  to  150°  F. 
in  order  to  kill  the  rennin.  If  whey  is  not  brought  to  this  tempera^ 
ture  before  it  is  added  to  milk  or  cream,  the  rennin  in  it  will  cur- 
dle them.  It  should  be  cooled  before  being  mixed  with  cream  or 
milk. 

The  Determination  of  Percentages  in  Mixtures. — It  is  often  of 
great  importance  to  find  out  just  what  a  baby  has  been  taking  in 
order  to  know  how  to  change  the  food,  if  it  is  not  agreeing  with  it. 
To  do  this  it  is  necessary  to  determine  the  percentages  of  the  dif- 
ferent elements  in  the  food.  This  is  not  a  difficult  matter.  Sup- 
pose that  a  baby  is  taking  a  food  made  up  as  follows: 

Gravity  cream 12  ounces 

Skimmed  milk 18  ounces 

Lime  water ; 6  ounces 

Barley  water 12  ounces 

Milk  sugar 4  rounded  tablespoonfuls 

The  barley  water  is  made  with  two  teaspoonfuls  of  barley  flour 
in  a  pint  of  water. 

The  total  quantity  of  the  mixture  is  forty-eight  ounces.  Gravity 
cream  contains  16%  of  fat.  Twelve  ounces  of  gravity  cream  in  a 
forty-eight-ounce  mixture  will  give,  therefore,  12/48  of  16%  of  fat, 


CALORIC  VALUES  239 

or  4%  of  fat.  Both  gravity  cream  and  skimmed  milk  contain 
3.20%  of  protein.  There  are  thirty  ounces  of  gravity  cream  and 
skimmed  milk  in  the  mixture.  Thirty  ounces  in  a  forty-eight- 
ounce  mixture  will  give  30/48  of  3.20%  of  protein,  or  2.00%  of  pro- 
tein. Both  the  gravity  cream  and  the  skimmed  milk  also  contain 
4.50%  of  sugar.  Thirty  ounces  of  gravity  cream  and  skimmed  milk 
in  a  forty-eight-ounce  mixture  will,  therefore,  furnish  30/48  of  4J^, 
which  is  the  same  as  30/48  of  9/2,  or  almost  3.00%  of  milk  sugar. 
Four  rounded  tablespoonfuls  of  milk  sugar  are  equal  to  two  ounces. 
Two  ounces  of  sugar  in  a  forty-eight-ounce  mixture  is  equal  to  2/48 
of  100%,  or  4%.  The  total  percentage  of  sugar  is,  therefore, 
7%.  Two  teaspoonfuls  of  barley  flour  in  a  pint  of  water  makes 
a  1.50%  decoction  of  starch.  Twelve  ounces  of  barley  water  of 
this  strength  in  a  forty-eight-ounce  mixture  will  give  12/48  of  1.50% 
or  about  0.35%  of  starch.  There  are  six  ounces  of  lime  water  in  the 
mixture  and  thirty  ounces  of  gravity  cream  and  skimmed  milk; 
^/30  of  100%  is  20%.  The  Ume  water  in  the  mixture  is,  therefore, 
20%  of  the  milk  and  cream.  The  mixture  thus  contains  4%  of  fat, 
7%  of  milk  sugar,  2%  of  protein  and  0.35%  of  starch,  while  the 
lime  water  is  present  in  the  proportion  of  20%  of  the  cream  and 
milk. 

Method  of  Determining  the  Caloric  Value  of  Mixtures  of  Modi- 
fied Milk. — The  method  detailed  below  is  longer  than  some  of  the 
other  methods  in  common  use.  It  is  more  accurate  than  many  of 
them,  however,  and  has  this  in  its  favor,  namely,  it  is  impossible  to 
carry  it  out  without  fully  understanding  what  the  caloric  value  of 
food  really  means. 

Suppose  that  a  baby  is  taking  thirty  ounces  of  a  food  containing 
4%  of  fat,  6%  of  sugar,  2.25%  of  protein  and  0.75%  of  starch. 
Thirty  ounces  is  equal  to  900  cubic  centimeters.  Four  per  cent  fat 
means  that  there  are  4  grams  of  fat  in  each  100  cubic  centimeters 
of  food.  The  baby  is  taking  900  cubic  centimeters  of  food,  that  is, 
it  is  taking  nine  times  the  amount  of  fat  in  100  cubic  centimeters  of 
food,  or  nine  times  4  grams,  which  is  36  grams.  The  caloric  value 
of  1  gram  of  fat  is  9.3  calories.  Thirty-six  grams  of  fat  will  give 
thirty-six  times  9.3  calories,  which  is  equal  to  334.8  calories. 

The  caloric  value  of  sugar,  starch  and  protein  is  the  same,  each 
gram  yielding  4.1  calories.^  The  caloric  value  of  these  elements 
can,  therefore,  be  calculated  at  the  same  time,  There  are  6  grams 
of  sugar,  2.25  grams  of  protein  and  0.75  grams  of  starch,  or  a  total 
of  9  grams  in  each  100  cubic  centimeters  of  the  food.  There  are, 
therefore,  nine  times  9  grams,  or  81  grams,  in  900  cubic  centimeters 
1  The  caloric  value  of  a  gram  of  milk  sugar  is  in  reality  3.78  calories. 


240  CALORIC  VALUES 

of  food.  One  gram  is  equivalent  to  4.1  calories.  Eighty-one  grams 
provide  81  x  4.1  calories  or  332.1  calories.  The  sum  of  the  334.4 
calories  furnished  by  the  fat  and  the  332.1  calories  furnished  by 
the  sugar,  starch  and  protein  is  666.9  calories,  which  is,  therefore, 
the  caloric  value  of  the  mixture. 

The  caloric  value  of  the  food  is  of  importance  only  in  its  relation 
to  the  weight  of  the  baby.  Suppose  that  the  baby  who  has  been 
taking  the  above  food  weighs  eleven  pounds.  Dividing  the  num- 
ber of  calories  in  the  food  by  the  weight  gives  the  number  of  cal- 
ories which  it  gets  per  unit  of  weight.  That  is,  666.9  calories  di- 
vided by  eleven  gives  60  calories,  which  is  the  number  of  calories 
which  it  is  getting  per  pound  of  weight. 

A  kilogram  is  equal  to  two  and  two-tenths  pounds.  Eleven 
pounds  is  equal,  therefore,  to  5  kilograms.  Dividing  666.9  calories 
by  five  gives  the  number  of  calories  which  the  baby  is  getting  per 
kilogram  of  body  weight,  that  is,  133  calories. 

A  simple,  but  less  accurate,  method  of  calculating  the  caloric 
value  of  a  modified  milk  mixture  is  that  recommended  by  Fraley 
(Archives  of  Pediatrics,  1912,  xxix,  123).  Letting  F  =  the  per- 
centage of  fat,  S  the  percentage  of  sugar  and  starch,  P  the  per- 
centage of  protein  and  Q  the  total  quantity  of  food,  then 

2F4-P+SxlJ^Q  =  calories. 

This  formula  always  gives  the  caloric  value  a  little  lower 
than  it  really  is.  It  gives,  for  example,  637  calories  as  the 
value  of  the  food  just  calculated  above,  when  the  real  value 
is  666.9  calories. 

Still  another  method,  which  is  also  accurate,  is  that  recom- 
mended by  Bowditch  (Jour.  A.  M.  A.,  1909,  liii,  1265).  The  caloric 
value  of  a  food  is  very  easily  calculated  by  this  method  by  the  use 
of  a  table. 

The  Method  of  Determining  the  Protein  Content  of  Mixtures  of 
Modified  Milk. — It  is  very  easy  to  determine  the  protein  content 
of  a  food  by  using  the  same  principle  employed  in  estimating  the  ca- 
loric value.  Suppose  that  a  baby  weighing  fifteen  pounds  is  taking 
forty-eight  ounces  of  a  food  containing  2.50%  of  protein.  Forty- 
eight  ounces  is  equal  to  1440  c.  c.  There  are  2.5  grams  of  protein 
in  each  100  c.  c.  of  food,  or  14.4  x  2.5  grams  in  the  whole  amount. 
14.4  X  2.5  grams  =  36  grams.  The  baby  weighs  fifteen  pounds. 
It  gets,  therefore,  2.4  grams  of  protein  per  pound  of  body  weight 
in  this  food.  Fifteen  pounds  is  6.8  kilograms.  Dividing  36  grams 
by  6.8  gives  5.3  grams,  which  is  the  amount  of  protein  which  the 
baby  gets  per  kilogram  of  weight  from  this  food. 


PANCREATIZATION  241 

The  Pancreatization  of  Modified  Milk. — Pancreatized  milk  pre- 
pared with  "Peptogenic  Milk  Powder"  is  often  given  to  infants. 
The  objection  to  the  use  of  pancreatized  milk  prepared  in  this  way 
is  that,  if  the  directions  as  to  the  preparation  of  the  food  are  fol- 
lowed, it  is  a  routine  food  and  not  susceptible  of  variation  to  meet 
the  needs  of  the  individual  infant  at  the  given  time.  It  is  far  bet- 
ter to  make  a  mixture  to  meet  the  indications  in  the  given  case  and 
then  to  pancreatize  it  by  the  addition  of  one  of  the  "peptonizing" 
powders  or  tablets.  In  this  way  the  advantages  of  a  food  suited 
to  the  needs  of  the  baby  and  of  predigestion  of  the  food  are  both 
retained. 

The  food  may  be  heated  at  "blood  heat,"  not  over  115°  F.,  for 
ten  minutes  and  then  brought  quickly  to  a  boil.  The  ferments  are 
destroyed  by  the  boiling  and  the  food  will,  therefore,  not  become 
bitter.  It  is  better  to  add  a  part  of  the  contents  of  a  "  peptonizing  " 
tube  or  part  of  a  tablet  to  each  feeding  just  before  it  is  to  be  used. 
The  feeding  is  then  heated  for  from  ten  minutes  to  fifteen  minutes 
at  blood  heat,  or  from  100°  F.  to  115°  F.,  being  allowed  to  drop  to 
100°  F.  toward  the  end  of  this  time,  and  immediately  given  to  the 
baby.  The  advantage  of  this  method  is  that  the  ferments  are 
still  active  when  the  food  is  ingested  and  will  continue  to  act  until 
the  reaction  of  the  stomach  contents  becomes  acid.  The  contents 
of  a  "peptonizing"  tube,  or  a  "peptonizing"  tablet,  are  usually 
intended  for  the  pancreatization  of  a  pint  of  milk.  The  proportion 
of  milk  in  each  feeding  being  known,  it  is  a  simple  matter  to  cal- 
culate how  much  of  the  powder  or  tablet  to  add.  "Peptonized 
milk"  prepared  by  the  so-called  "cold  process"  is,  of  course,  not 
predigested  at  all,  because  the  pancreatic  enzymes  do  not  act  in  the 
cold.  The  only  opportunity  which  they  have  to  act,  when  milk  is 
prepared  by  this  process,  is  after  they  are  taken  into  the  stomach. 
Their  action  ceases,  however,  when  the  reaction  of  the  stomach 
contents   becomes   acid. 

PROPRIETARY   FOODS 

The  first  thing  to  be  remembered  when  considering  the  propri- 
etary foods  is  that  there  are  only  certain  food  elements,  namely, 
fat,  carbohydrates,  protein  and  mineral  matters.  There  can,  there- 
fore, be  nothing  in  the  proprietary  foods  except  these  elements. 
All  of  the  elements  are  easy  to  procure  and  can  be  put  into  modi- 
fied milk  in  any  form  and  in  any  amount  desired. 

It  is  often  said  that  a  certain  baby  did  not  do  well  on  modified 
milk  but  at  once  began  to  thrive  when  given  a  certain  proprietary 


242  PROPRIETARY  FOODS 

food.  Such  a  statement  is  undoubtedly  true.  This  does  not 
show,  however,  that  this  proprietary  food  is  better  than  modified 
milk.  It  merely  shows  that  the  combination  of  the  different  food 
elements  in  this  food  was  the  one  suitable  for  this  baby.  There  was 
nothing  in  the  proprietary  food  which  could  not  have  equally  well 
been  put  in  a  modified  milk.  The  difficulty  with  modified  milk  was " 
that  the  person  who  prescribed  it  did  not  understand  or  know  how 
to  meet  the  indications  in  the  given  case.  If  he  had,  the  baby 
would  have  thrived  as  well  on  modified  milk  as  on  the  proprietary 
food.  It  is  noteworthy  in  this  connection  that  while  much  is  said 
in  praise  of  a  given  food  when  a  baby  does  well  on  it,  nothing  is 
said  about  all  the  other  proprietary  foods  upon  which  it  did  not  do 
well. 

A  great  objection  to  proprietary  foods  is  that  their  use  tends  to 
develop  slip-shod  methods  on  the  part  of  physicians.  They  get  in 
the  habit  of  choosing  proprietary  foods  at  random  or  of  using  some 
food  constantly,  because  they  have  seen  a  number  of  babies  thrive 
on  it,  instead  of  thinking  for  themselves  and  endeavoring  to  pre- 
scribe a  milk  modification  to  fit  the  needs  of  the  individual  baby  at 
the  given  time.  Another  objection  to  the  proprietary  foods  is 
that,  being  led  by  the  advertisements  of  the  manufacturers  of  these 
foods  to  beheve  that  the  artificial  feeding  of  infants  is  a  very  sim- 
ple matter,  parents  attempt  to  feed  their  own  babies  on  such  foods 
instead  of  employing  a  physician  to  prescribe  the  feeding.  The 
results  are  often  unfortunate,  to  say  the  least. 

A  still  further  objection  to  proprietary  foods  is  their  cost.  It  is 
a  self-evident  proposition  that  the  people  who  buy  the  foods  have 
to  pay  for  the  manufacture  and  advertising  of  the  food,  as  well  as  a 
profit  to  the  manufacturer  and  various  middlemen,  neither  the 
manufacturer  nor  the  middlemen  being  in  business  "for  their 
health."  This  expense  is  unnecessary,  because  modifications  of 
milk  containing  everything  which  is  in  these  proprietary  foods  can 
be  readily  prepared  from  simple  materials  in  the  home.  The  com- 
position of  some  of  the  proprietary  foods  in  most  conmaon  use  in 
this  country  is  given  in  the  table  on  pages  244-245. 

It  is  noteworthy  that  these  proprietary  foods  can  be  divided  into 
four  main  groups.  I.  The  condensed  milks,  sweetened  or  un- 
sweetened. II.  The  malted  foods,  in  which  the  whole,  or  a  con- 
siderable part,  of  the  carbohydrates  is  in  the  form  of  maltose  and 
the  various  dextrins.  III.  The  foods  in  which  there  is  a  con- 
siderable proportion  of  starch  in  addition  to  the  soluble  carbohy- 
drates. IV.  The  foods  which  are  almost  entirely  composed  of 
starch.    The  different  groups  are  worthy  of  separate  consideration. 


PROPRIETARY  FOODS  243 

I.  The  Condensed  Milks. — Condensed  milk  is  almost  never 
given  undiluted.  The  customary  dilution  is  one  part  of  con- 
densed milk  to  nine  parts  of  water.  This  dilution  gives  a  mixture, 
if  Eagle  Brand  Condensed  Milk  is  used,  containing  0.96%  of  fat, 
5.49%  of  sugar  and  0.80%  of  protein.  This  analysis  explains  why 
a  baby  that  has  a  disturbance  of  digestion  from  overfeeding  will 
do  well  on  condensed  milk.  It  will  do  equally  well  on  a  modified 
fresh  milk  containing  the  same  percentages.  It  is  also  evident, 
from  this  analysis,  that  a  very  large  amount  of  this  food  must  be 
taken  to  cover  the  caloric  and  protein  needs  of  a  baby.  The  rela- 
tion between  the  carbohydrates  and  fat  is  not  a  proper  one  for  the 
normal  well  infant  and  the  protein  is  too  low.  The  caloric  value  of 
the  food  is  even  lower,  when  the  unsweetened  condensed  milks  are 
used.  Condensed  milk  is,  moreover,  not  a  uniformly  sterile  prod- 
uct, as  is  commonly  supposed.  Some  specimens  are  sterile,  but 
many  are  not.  The  bacterial  content  of  some  of  them  is  as  high  as 
10,000,000  per  cubic  centimeter.^ 

n.  The  Malted  Foods. — The  chief  reasons  that  foods  of  this 
class  agree  with  so  many  babies  are  that  the  carbohydrates  are  in 
the  form  of  maltose  and  dextrins  and  that  the  dextrins,  by  their 
colloidal  action,  favor  the  digestion  of  protein.  Mellin's  Food  and 
Mead's  Dextri-Maltose  are  examples  of  this  class.  So  also  is 
Horlick's  Malted  Milk  which,  however,  differs  from  those  first  men- 
tioned, as  do  also  Laibose  and  Allenbury's  Foods,  No.  1  and  No.  2, 
in  that  they  also  contain  dried  milk  in  addition  to  malt  sugar  and 
dextrins.  Those  that  contain  dried  milk  are  intended  to  be  mixed 
with  water.  When  so  mixed,  they  are,  in  spite  of  the  dried  milk 
which  they  contain,  deficient,  in  that  the  fat  and  protein  content  of 
the  mixture  is  too  low.  When  those  that  do  not  contain  dried  milk 
are  mixed  with  water,  the  mixtures  contain  practically  no  fat  and 
but  little  protein.  When  mixed  with  milk  or  cream,  the  result  is  a 
modified  milk  with  the  sugar  in  the  form  of  maltose  and  the  dextrins. 
Such  modified  milks  agree  when  for  any  reason  milk  sugar  is  con- 
traindicated  and  maltose  and  the  dextrins  are  needed.  It  is  inad- 
visable, however,  to  use  these  foods  according  to  the  directions 
which  come  with  them,  because,  if  this  is  done,  the  feeding  becomes 
routine  and  the  food  is  not  fitted  to  the  individual  baby.  It  is  far 
better  to  modify  the  milk  to  fit  the-needs  of  the  special  infant  and 
then,  if  milk  sugar  is  contraindicated,  to  add  one  of  these  combina- 
tions of  maltose  and  the  dextrins  to  the  mixture  in  its  place.  Which 
food  is  chosen  will  depend  on  the  relative  proportions  of  maltose 
and  the  dextrins  which  are  desired.    The  same  result  may  be 

*  Jordan  and  Mott:  American  Journal  of  Public  Hygiene,  1910,  xx,  391. 


244 


PROPRIETARY  FOODS 


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246 


PROPRIETARY  FOODS 


obtained  by  adding  a  cereal  gruel  and  then  dextrinizing  the 
food. 

in.  The  Sugary  and  Starchy  Foods. — Examples  of  the  foods 
which  contain  considerable  amounts  of  starch  in  addition  to 
various  combinations  of  the  various  sugars  are  Eskay's  Albumen- 
ized  Food,  Nestl^'s  Food  and  "AUenbury's"  Food  No.  3.  The 
fat  content  of  the  foods  of  this  class  is,  a,s  a  rule,  almost  infinites- 
imal. When  diluted  with  water  they  amount  to  but  little  more 
than  a  starch  and  sugar  mixture.  When  mixed  with  some  form 
of  milk  they  correspond  to  a  modified  milk  prepared  with  a  cereal 
diluent. 

IV.  The  Starchy  Foods. — Imperial  Granum  and  Ridge's  Food 
are  striking  examples  of  the  starchy  foods,  or  rather  of  the  starch 
foods.  The  composition  of  these  two  foods  is  almost  identical. 
The  following  comparison  of  the  analyses  of  Imperial  Granum  and 
ordinary  wheat  flour  is  interesting  and  instructive  (Table  48): 

TABLE  48 


Fat 


Sugar 


Protein 


Starch 


Ash 


Imperial  Granum 
Wheat  flour  2 


1.04 
1.00 


1.80 
0.00 


(dextrose  0.42 
jdextrins  1.38 


14.00 
11.40 


73.54 

75.10  (total 
carbohy- 
drates) 


0.39 
0.50 


It  is  evident  that  the  sum  of  the  sugars  and  starch  in  Imperial 
Granum  is  essentially  the  same  as  the  total  carbohydrate  content 
of  wheat  flour.  Heating  wheat  flour  will  change  a  small  per- 
centage of  the  starch  into  dextrin  and  dextrose.  It  would  seem 
cheaper  for  people  to  bake  their  own  flour  than  to  pay  someone 
else  to  do  it  for  them,  even  if  they  do  put  it  up  in  a  box  and  give  it 
another  name. 


THE    FEEDING   OF   INFANTS   AFTER   WEANING   AND   DURING   THE 
SECOND   YEAR 

The  average  baby  that  has  done  well,  whether  it  has  been  fed  on 
the  breast  or  artificially,  will  be  taking,  when  it  is  about  ten 
months  old,  a  mixture  of  whole  milk  and  barley  water.  It  will  be 
taking  five  feedings  at  three-hour  intervals,  beginning  at  six  in  the 

^  Analysis  given  by  Holt.    Diseases  of  Infancy  and  Childhood,  1911,  p.  162. 
*  Chemical  Composition  of  American  Food  Materials.    Atwater  and  Bryant. 
Bulletin  No.  28,  U.  S.  Department  of  Agriculture. 


FEEDING  OF  OLDER  CHILDREN  247 

morning  and  ending  at  six  at  night.  If  it  has  shown  a  tendency  to 
constipation,  it  will  probably  be  taking  some  orange  juice. 

It  may  be  remarked  here,  parenthetically,  that  orange  juice  is 
not  a  necessary  part  of  a  baby's  diet,  as  many  people  suppose.  It  is 
advisable  to  give  it,  if  the  food  is  pasteurized  or  boiled,  in  order  to 
guard  against  the  possible  development  of  scurvy.  It  is  also  useful, 
if  there  is  a  tendency  to  constipation.  It  will,  moreover,  sometimes 
restore  a  failing  appetite.  In  such  cases,  however,  it  is  probable 
that  the  loss  of  appetite  is  an  early  symptom  of  scurvy.  It  is  wiser 
to  give  it  for  definite  indications  than  to  use  it  as  a  routine  measure, 
although  it  probably  does  no  harm  in  most  instances,  even  if  it  is 
not  indicated.  The  best  time  to  give  orange  juice  is  one  hour 
before  a  feeding,  when  the  stomach  is  comparatively  empty.  It  is 
less  likely  to  disturb  the  digestion  when  given  at  this  time.  It  is 
rarely  advisable  to  give  more  than  two  tablespoonfuls  to  a  young 
baby.  The  whole  amoimt  for  the  day  should  be  given  at  one  time. 
It  may  be  diluted  with  water  and  sweetened  with  cane  sugar  if 
desired. 

The  simple  cereals  should  be  begun  about  this  time.  The  most 
easily  digestible  are  barley  jelly,  oat  jelly  and  farina.  The  barley 
jelly  is  made  from  barley  flour,  the  oat  jelly  from  oat  flour  or  oat- 
meal thoroughly  cooked  and  strained.  Two  or  three  rounded 
tablespoonfuls  of  flour  to  a  pint  of  water  will  make  a  jelly.  It 
should  be  cooked  at  least  an  hour.  When  oatmeal  is  used  it  should 
be  cooked  at  least  four  hours.  All  cereals  which  are  given  to 
infants  and  children  must  be  thoroughly  cooked.  Even  the  simple 
ones  should  be  cooked  several  hours,  in  spite  of  the  fact  that  the 
directions  on  the  package  may  state  that  fifteen  to  twenty  minutes 
is  sufficient.  The  most  satisfactory  way  of  cooking  them  is  in  a 
"fireless  cooker. " 

In  beginning  to  feed  cereals,  they  should  be  given  at  the  begin- 
ning of  the  9  A.  M.  and  6  P.  M.  feedings.  Some  of  the  baby's 
mixture  should  be  put  on  them,  never  cream  or  top  milk.  They 
should  be  salted,  but  no  sugar  should  be  used.  If  babies  begin  to 
eat  cereals  without  sugar,  they  learn  to  like  them  in  that  way  and, 
as  they  grow  older,  do  not  expect  to  have  them  or  other  foods 
smothered  in  sugar.  The  chances  of  the  development  of  a  sugar 
indigestion  in  the  future  are  thus  much  diminished.  It  is  well  to 
begin  with  a  level  tablespoonful  of  cereal,  increasing  the  amount  as 
necessary. 

It  is  usually  wiser  to  wait  a  few  weeks  after  beginning  to  give 
cereals,  before  giving  beef  juice  or  broth.  The  most  satisfactory 
form  of  beef  juice  is  the  freshly  prepared  beef  juice.    This  is  made 


248  FEEDING  OF  OLDER  CHILDREN 

by  half-broiling  a  piece  of  round  steak.  The  steak  should  then  be 
cut  into  small  pieces  and  the  juice  squeezed  out  with  a  beef  press 
or  a  lemon  squeezer.  Beef  juice  prepared  in  this  way  contains 
about  0.60%  of  fat  and  2.90%  of  protein,  with  a  considerable 
amount  of  extractive  matters.  Dish  gravy,  as  it  is  called,  is  not 
the  same  thing.  It  contains  a  large  amount  of  cooked  fat  and  is 
often  highly  indigestible.  The  various  manufactured  beef  juices, 
meat  extracts  and  similar  preparations  are  not  as  good  as  the  ex- 
pressed beef  juice  and  should  be  used  only  when  it  is  impossible  to 
obtain  fresh  beef  juice. ^  Beef  juice  may  be  given  plain  or  diluted 
with  water.  It  should  be  salted  to  taste.  It  is  wiser  to  begin 
with  one  teaspoonful,  gradually  increasing  the  amount  to  six 
teaspoonfuls,  or  one  ounce.  Babies  should  never  be  given  more 
than  two  ounces  of  beef  juice,  even  in  their  second  year.  Beef  juice 
is  liable  to  disturb  the  digestion  of  some  babies  and  not  infrequently 
makes  other  babies  nervous  and  sleepless.  It  is  always  well,  there- 
fore, to  warn  mothers  of  this  possibility  when  beef  juice  is  first 
given.  The  best  time  to  give  beef  juice  is  at  the  beginning  of 
the  noon  feeding. 

Mutton  broth  and  chicken  broth  must  be  very  carefully  pre- 
pared. The  fat  must  be  entirely  skimmed  off  and  the  broth  should 
be  thick  enough  to  form  a  jelly  when  cold.  Two  ounces  should 
be  given  in  the  beginning  and  this  amount  increased  to  four  ounces 
later.  The  broth  should  also  be  given  at  the  beginning  of  the  noon 
feeding,  beef  juice  being  given  one  day,  broth  the  next,  and  so  on. 
It  must  be  remembered  that  the  nutritive  value  of  broth  is  prac- 
tically nil.  The  broth  serves  merely  as  a  vehicle  for  other  food  and 
as  a  stimulant  to  the  appetite. 

It  is  well  to  begin  to  give  breadcrumbs  and  zwiebach  in  the  broth 
and  beef  juice  in  the  course  of  a  few  weeks.  At  the  same  time  the 
baby  may  be  given  bread  or  zwiebach  "in  its  hand"  in  order  that 
it  may  learn  how  to  eat. 

It  is  usually  possible  to  leave  out  the  cereal  diluent  when  the 
baby  is  a  year  old  and  give  plain  milk.  In  many  instances,  how- 
ever, it  is  advisable  to  continue  to  give  an  ounce  of  barley  jelly  or 
oat  jelly  in  each  feeding  until  the  baby  is  one  and  one-half  years 
old.  The  variety  of  cereals  may  be  increased  by  the  addition  of 
Cream  of  Wheat,  Ralston  and  rice  when  the  baby  is  a  year  old. 
At  about  fourteen  months  it  may  have  milk  toast  and  bread  and 
milk.    If  desired,  a  part  of  the  milk  may  be  given  in  the  form  of 

1  See  Bull.  No.  114,  Bureau  of  Chemistry,  U.  S.  Dept.  of  Agriculture, 
"  Meat  Extracts  and  Similar  Preparations,  and  Jour.  A.  M.  A.,  1909,  liii, 
1754,  "Meat  and  Beef  Juices." 


FEEDING  OF  OLDER  CHILDREN  249 

junket.  If  the  baby  is  constipated,  prune  juice  and  pulp  and  the 
inside  of  baked  apples  may  be  added  at  this  time  or  even  earlier^ 
Plain  white  crackers,  such  as  soda  crackers,  Uneeda  Biscuits  or 
pilot  wafers  may  also  be  given,  either  plain  or  in  the  form  of  cracker 
toast. 

It  is  wiser,  in  general,  not  to  begin  to  give  eggs  until  babies  are 
about  eighteen  months  old.  Many  infants  are  poisoned  by  eggs. 
It  is  always  advisable,  therefore,  to  begin  eggs  veiy  cautiously. 
Eggs  should  be  given  at  first  either  soft  boiled  for  about  two  min- 
utes, or  coddled  for  about  four  minutes.  If  eggs  do  not  disagree, 
the  baby  may  be  given  an  egg  every  other  day,  and  by  the  time 
it  is  two  years  old,  an  egg  daily.  This  may  be  given  in  the  morning 
or  at  noon  in  place  of  the  broth  and  beef  juice.  At  one  and  one- 
half  years,  baked  potato,  plain  boiled  macaroni,  rice  and  Wheat 
Germ  may  be  given.  Baked  custard,  plain  blanc  mange  and  plain 
boiled  tapioca  may  also  be  given  as  desserts,  if  desired.  There  is 
no  objection  at  this  time  to  putting  butter  on  the  bread. 

This  dietary  is  sufficient  until  the  baby  is  nearly  two  years  old, 
when  meat  may  be  begun.  The  most  easily  digestible  forms  of 
meat  are  the  white  meat  of  chicken,  mutton  and  lamb  chop  and 
scraped  beef.  A  reasonable  dietary  for  a  baby  of  two  years  is  whole 
milk,  butter,  mutton  broth,  chicken  broth,  beef  juice,  soft  boiled 
eggs,  coddled  eggs,  dropped  eggs,  white  meat  of  chicken,  lamb 
chop,  mutton  chop,  scraped  beef,  French  bread,  stale  bread, 
toasted  bread,  whole  wheat  bread,  milk  toast,  zwiebach,  plain 
white  crackers,  plain  Educator  crackers,  barley  jelly,  oatmeal, 
Cream  of  Wheat,  Wheat  Germ,  Ralston,  farina,  rice,  baked  potato, 
plain  boiled  macaroni,  orange  juice,  baked  apples,  stewed  prune 
pulp  and  juice,  junket,  baked  custard,  corn  starch  pudding,  plain 
blanc  mange,  plain  tapioca.  It  is  not  advisable,  as  a  rule,  to  begin 
green  vegetables  until  the  baby  is  two  and  a  half  years  old. 

In  most  instances  the  hours  of  feeding  are  changed  when  the 
baby  is  from  sixteen  to  eighteen  months  old.  At  that  time  the 
baby  gets  some  milk  when  it  wakes  up  in  the  morning.  It  has  its 
breakfast  between  8  and  8:30.  It  gets  some  more  milk,  or  some 
milk  with  a  piece  of  bread  or  a  cracker,  at  11  or  11:30,  before  its 
nap.  It  has  its  dinner  when  it  wakes  up  from  its  nap  at  1:30  or  2, 
and  its  supper  at  5:30. 


CHAPTER  XIX 
THE  FEEDING  OF  PREMATURE  INFANTS 

All  the  functions  of  digestion  of  premature  infants  are  feeble. 
In  a  general  way,  the  younger  the  baby,  the  feebler  are  the  digest- 
ive powers.  Little  is  known  positively  as  to  the  absolute  or  rel- 
ative strength  of  the  various  digestive  ferments  in  the  premature. 
It  is  probable,  however,  that  the  tolerance  for  sugar  is  greater  than 
that  for  fat  and  protein.  The  amylolytic  function  may  be  present 
at  birth,  but  is  relatively  undeveloped  and  should  not  be  called 
upon.  It  is  presumable  that  the  metaboUc  processes  are  less  active 
in  the  premature  than  in  the  full-term  baby  and  that  the  utilization 
of  the  food  ingested  is,  therefore,  less  complete.  There  is,  however, 
no  proof  of  this  supposition.  It  is  a  well-known  fact  that  small 
bodies  have  a  greater  surface  area  in  proportion  to  their  mass  than 
have  large  bodies.  The  loss  of  heat  is,  therefore,  relatively  greater 
in  proportion  to  the  weight  in  small  than  in  large  bodies.  A  pre- 
mature infant  would,  therefore,  be  expected  to  require  more 
nourishment  in  proportion  to  its  weight  than  would  the  full-term  in- 
infant.  Another,  and  perhaps  more  important,  reason  why  prema- 
ture infants  lose  heat  more  rapidly  than  full-term  infants  is  that 
they  have  very  little  fat  tissue  to  act  as  a  blanket  to  keep  the  heat 
in.  They  have,  moreover,  relatively  more  "active"  tissue,  i.  e., 
muscle,  than  full-term  infants  and  it  is  apparently  the  active  tis- 
sue which  uses  up  energy  and  not  the  fat,  which  is  inactive.  The 
difficulties  in  the  way  of  the  successful  feeding  of  premature  infants 
are,  therefore,  obvious. 

All  the  reasons  which  prove  that  human  milk  is  the  best  food  for 
the  full-term  infant  are  doubly  applicable  in  the  case  of  the  pre- 
mature infant.  A  premature  infant  should,  therefore,  always  be 
given  breast-milk,  if  it  can  possibly  be  obtained.  None  but  the 
strongest  infants  or  those  but  little  premature  should,  however, 
be  put  to  the  breast.  The  vast  majority  of  them  are  too  feeble  to 
nurse  satisfactorily  and  are  unable  to  bear  the  handling  and  expo- 
sure consequent  on  being  put  to  the  breast.  Many  a  premature 
infant  has  had  what  few  chances  it  had  of  survival  destroyed  in 
this  way.  The  milk  should  be  taken  from  the  breast  and  fed  to 
the  baby.    There  is  some  difference  of  opinion  as  to  whether  it  is 

250 


THE  FEEDING  OF  PREMATURE  INFANTS       251 

better  for  the  new-bom  premature  baby  to  have  colostrum  or  an 
established  breast-milk.  The  evidence  on  the  two  sides  is  incom- 
plete, and  the  question  must  be  considered  as  still  a  mooted  one. 
In  most  instances  the  baby  will  naturally  get  its  own  mother's 
milk,  that  is,  colostrum,  while  if  it  gets  another  woman's  milk,  it 
will  usually  be  an  established  one.  For  practical  purposes,  either 
will  do. 

There  is  also  considerable  difference  of  opinion  as  to  whether  a 
premature  baby  should  be  fed  within  a  few  hours  after  birth, 
or  whether  it  should  not  be  fed  for  twelve  hours  or  for  twenty-four 
hours.  Those  who  believe  that  it  should  be  fed  very  soon  argue 
that  it  needs  nourishment  at  once,  because  of  its  prematurity  and 
feebleness,  while  those  who  believe  in  waiting  argue  that  Nature 
shows  that  a  full-term  baby  should  not  have  food  for  from  twenty- 
four  hours  to  forty-eight  hours,  since  it  does  not  provide  food  un- 
til this  time,  that  the  premature  baby  needs  rest  after  the  fatigue  of 
labor  more  than  does  the  full-term  baby,  and  that  it  is  even  less 
able  to  digest  food  in  the  first  few  hours  than  the  full-term  baby. 
On  the  whole,  it  is  probably  best  to  begin  to  feed  the  premature  in- 
fant when  it  is  about  twelve  hours  old. 

There  is  also  much  difference  of  opinion  as  to  the  intervals  at 
which  premature  babies  should  be  fed.  It  used  to  be  thought 
that,  on  account  of  the  small  amount  taken  at  a  feeding  and  the 
greater  need  for  food,  they  should  be  fed  every  hour  or  every  one 
and  one-half  hours.  Such  frequent  feedings  do  not  give  the  stom- 
ach a  chance  to  empty  itself,  however,  and  do  not  give  the  baby  a 
sufficient  opportunity  for  continued  sleep.  Ten  feedings  at  inter- 
val of  two  hours  during  the  day  and  of  four  hours  during  the  night 
meet  the  indications  better.  The  stomach  then  has  time  to  empty 
itself  and  the  baby  is  not  disturbed  too  often.  Czemy  and  Keller  ^ 
have  for  a  long  time  advocated  four-hour  intervals,  and  Litzen- 
berg  ^  has  recently  reported  some  extremely  good  results  in  a  series 
of  fifty  cases  fed  at  these  intervals.  His  results  show,  if  nothing 
more,  that  premature  babies  can  thrive  on  these  longer  intervals. 
An  additional  advantage  in  these  intervals  is  that  if  babies  do 
thrive  as  well  on  them  as  on  the  shorter  intervals,  the  care  and 
attendance  required  are  much  less. 

Caloric  Needs. — ^The  reason  why  the  caloric  needs  of  a  pre- 
mature baby  would  be  expected  to  be  greater  than  those  of  a  full- 
term  baby  have  already  been  mentioned.  Experience  has  shown, 
moreover,  that,  on  the  average,  premature  babies  that  are  thriving 

1  "Ernahrung  des  gesunden  Kindes,"  p.  685.    Quoted  by  Litzenberg. 
*  Amer.  Journal  of  Diseases  of  Children,  1912,  iv,  391. 


252       THE  FEEDING  OF  PREMATURE  INFANTS 

do  take  and  require  more  calories  per  Kilo  of  body  weight  than  do 
full-term  babies.^  The  average  quotient  is,  however,  not  as  high  as 
was  formerly  supposed.  Most  premature  babies  need  about  120 
calories  per  Kilo,  but  there  are  many  exceptions.  Some  premature 
babies  will  thrive  and  gain  on  as  little  as  70  calories  per  Kilo.  No 
attempt  should  be  made  to  reach  120  calories  per  Kilo  during  the 
first  few  days.  Thirty  calories  per  Kilo  is  as  much  as  it  is  wise  to 
give  in  the  first  twenty-four  hours  of  feeding.  This  amount 
should  be  gradually  increased  each  day,  watching  carefully  for 
symptoms  of  indigestion,  and  diminishing  it  if  these  appear.  In 
most  instances,  120  calories  per  Kilo  can  be  given  in  about  tea 
days.  Very  few  are  able  to  utilize  more  than  130  calories  per  Kilo. 
If  this  amount  is  exceeded,  they  are,  in  most  instances,  upset. 

Character  of  Food. — The  first  food  given  should  be  breast- 
milk  diluted  with  an  equal  amount  of  water  or  a  3%  solution  of 
milk  sugar.  The  dilution  should  be  diminished  from  day  to  day. 
In  most  instances  undiluted  breast-milk  can  be  given  in  from  four 
days  to  a  week.  If  it  is  impossible  to  obtain  breast-milk,  the  best 
substitute  is  modified  cow's  milk.  It  is  very  important  to  begin 
with  very  weak  mixtures  in  order  not  to  upset  the  digestion  in  the 
beginning.  It  is  very  easy  to  kill  a  premature  baby  or  to  disturb 
its  digestion  so  much  that  a  long  time  is  required  to  remedy  it  by 
giving  too  strong  a  mixture  in  the  beginning.  On  the  other  hand, 
it  is  very  easy  to  strengthen  the  mixture,  if  the  baby  is  not  satis- 
fied. It  is  never  a  mistake  to  give  too  weak  a  mixture;  always  a 
mistake  to  give  a  strong  one.  Whey  mixtures  are  better  than 
ordinary  mixtures,  because  the  protein  is  in  a  more  easily  digestible 
form  and  hence  throws  less  work  on  the  feeble  digestive  organs. 
The  following  mixtures  are  suitable  ones: 

Fat 1.00% 

Milk  sugar 4.00% 

Total  proteins 0.25% 

Lime  water 25%  of  the  cream  and  milk  in  the  mixture. 

Fat 1.00% 

■    Milk  sugar 4.50% 

Total  proteins 0.60% 

Lime  water 25%  of  the  cream  and  milk  in  the  mixture. 

It  is  wiser  to  split  the  protein  in  these  mixtures,  making  the 
whey  protein  and  the  casein  the  same.    The  mixture  should  be 

1  Morse:  Amer.  Jour,  of  Obstetrics,  1905,  li,  589;  Rott:  Zeitschr.  f.  Kinder- 
heilk,  1913,  v,  134;  Hess:  Amer.  Jour.  Diseases  of  Children,  1911,  ii,  302; 
Zahorsky:  Baby  Licubators,  1905. 


THE  FEEDING  OF  PREMATURE  INFANTS        253 

gradually  strengthened  to  cover  the  caloric  needs,  due  attention 
being  paid  to  the  condition  of  the  stools  in  deciding  which  element 
or  elements  to  strengthen. 

Amount  of  Food. — Whether  the  food  is  breast-milk  or  modified 
milk,  it  is  better  to  begin  by  giving  one  drachm  (5  c.  c.)  at  a 
feeding.  If  the  baby  is  not  satisfied,  it  is  very  easy  to  gradually 
increase  the  amount.  It  should  be  increased  every  day  or  every 
few  feedings,  if  necessary.  No  harm  can  be  done  in  giving  too 
little  at  first;  irreparable  harm  may  be  done  by  giving  too  much. 

Finally,  always  begin  to  feed  premature  babies  with  small 
amounts  of  a  very  weak  food  and  increase  the  strength  and  amount 
at  a  feeding  as  rapidly  as  the  individual  baby's  digestion  will  allow, 
bearing  in  mind  that  it  is  less  dangerous  to  give  too  small  amounts 
and  too  weak  a  food  than  to  give  too  large  amounts  and  too  strong 
a  food.  If  a  premature  baby's  digestion  is  disturbed,  it  is  not  safe 
to  give  a  cathartic  freely  and  starve  it.  Like  atrophic  babies,  they 
cannot  bear  starvation,  but  must  be  fed. 

Water. — Premature  babies,  because  of  the  high  temperature 
and  dryness  of  the  air  by  which  they  are  surrounded,  need  a  con- 
siderable amount  of  water.  It  is  estimated  that  the  daily  ingestion 
of  liquid  should  be  one-sixth  of  the  body  weight. 

Methods  of  Feeding. — It  is  seldom  advisable  to  put  a  prema- 
ture baby  to  the  breast,  because  it  is  usually  too  feeble  to  nurse 
well  and  because  the  handling  and  exposure  consequent  on  being 
put  to  the  breast  overtax  the  vitality  too  severely.  When  the  infant 
is  strong  enough  to  take  food  from  a  nipple,  it  should  be  fed  from 
the  bottle.  Many  babies  are  not  strong  enough  to  do  this,  how- 
ever, and  have  to  be  fed  in  some  other  way.  The  most  satisfactory 
way  to  feed  such  babies  is  with  the  Breck  feeder.  This  consists 
essentially  of  a  graduated  glass  tube,  open  at  both  ends.  On  the 
smaller  end  is  a  nipple  about  the  size  of  the  rubber  of  a  medicine 
dropper.  This  is  perforated  and  goes  into  the  baby's  mouth.  On 
the  other  end  is  a  large  rubber  finger-cot.  By  squeezing  the 
finger-cot,  milk  is  forced  into  the  baby's  mouth  and  efforts  at 
sucking  aided  or  induced.  Some  babies  are  too  feeble  to  take  food 
even  in  this  way,  and  have  to  be  fed  with  a  medicine  dropper.  If  a 
baby  does  not  take  its  food  well  by  any  of  these  methods,  there  is 
no  objection  to  feeding  it  with  a  tube.  In  fact,  it  often  saps  the 
baby's  vitality  less  to  be  fed  in  this  way  than  in  any  other.  The 
passage  of  the  tube  seldom  causes  much  strangling  and  vomiting, 
as  the  pharyngeal  reflex  is,  in  most  instances,  not  fully  developed. 
The  tube  should  be  passed  through  the  mouth,  not  through  the 
nose.    A  No.  9  or  No.  10  catheter  is  suitable.    It  should  be  passed 


254       THE  FEEDING  OF  PREMATURE  INFANTS 

in  about  fifteen  centimeters,  the  distance  from  the  gums  to  the 
cardia  in  full-term  babies  being  seventeen  centimeters  (6^  inches) 
and  less  in  the  premature  infant.  If  the  baby  is  fed  with  the  tube  it 
is  better  not  to  give  it  more  than  eight  feedings  a  day,  fewer,  if 
possible. 


SECTION  IV 

DISEASES  OF  THE  GASTROINTESTINAL 
CANAL 

CHAPTER  XX 

SPASM  OF  THE  PYLORUS 

Spasm  of  the  pylorus  is  more  common  in  infancy  than  is  hyper- 
trophic stenosis.  It  is  often  a  complication  of  stenosis  and  is  not 
infrequently  mistaken  for  it.  In  fact,  it  is  probable  that  a  very 
large  majority  of  the  cases  of  pyloric  stenosis  which  have  been 
reported  as  cured  by  medical  treatment  were  not  really  cases  of 
organic  stenosis  but  of  spasm. 

ETIOLOGY 

The  etiology  of  spasm  of  the  pylorus  in  infancy  is  very  obscure. 
It  apparently  occurs  most  commonly  in  excitable  and  nervous 
infants,  the  offspring  of  neurotic  parents.  Some  writers  believe 
that  the  normal  muscular  hyperirritability  at  this  age  predisposes 
to  pyloric  spasm  and  that  the  mechanical  irritation  of  the  food  or 
the  chemical  products  of  digestion  thus  directly  or  reflexly  cause 
spasm  when  they  would  not  in  later  life.  Others  beUeve  that 
disturbance  of  the  gastric  digestion  always  precedes  and  causes  the 
spasm.  However  this  may  be,  it  is  certain  that  spasm  of  the 
pylorus  occurs  much  more  frequently  in  artificially-fed  than  in 
breast-fed  babies.  A  hypersecretion  of  gastric  juice  has  been  found 
in  some  cases  and  hyperacidity  of  the  gastric  juice  in  others.  The 
favorable  results  in  many  cases  of  treatment  intended  to  neutraUze 
hyperacidity  make  it  seem  probable  that  this  is  one  of  the  causes,  at 
least,  of  this  condition.  How  large  a  proportion  of  the  cases  is  due 
to  this  cause  is  uncertain. 

SYMPTOMATOLOGY 

In  the  first  place,  the  baby  is  usually  of  the  excitable,  irritable 
and  neurotic  type.     It  is  much  more  often  artificially-fed  than 

255 


256  DIAGNOSIS 

breast-fed.  The  first  sjnnptom  is  vomiting.  It  may  appear  imme- 
diately after  birth,  but  usually  does  not  develop  for  several  weeks 
and  sometimes  not  until  the  baby  is  several  months  old.  In  the 
milder  cases  this  is  the  only  symptom.  It  is,  however,  often  pre- 
ceded and  accompanied  by  evidences  of  gastric  pain  and  distress. 
The  vomiting  is  at  times  explosive  and  at  others  not.  The  amount 
of  the  vomitus  does  not  ordinarily  exceed  the  amount  of  food 
taken  at  the  last  meal.  The  vomitus  shows,  as  a  rule,  little  or  no 
evidences  of  disturbance  of  the  digestion.  There  is  a  tendency  to 
constipation,  but  the  stools  show  plainly  that  a  considerable 
proportion  of  the  food  ingested  passes  through  the  pylorus  into  the 
intestine.    The  disturbance  of  nutrition  is  not  extreme. 

In  the  more  severe  cases  there  is  visible  peristalsis  in  addition 
to  the  symptoms  already  given  as  characteristic  of  the  milder 
type.  These  symptoms  are  more  marked  than  in  the  mild  cases, 
the  stools  show  less  fecal  residue  and  the  disturbance  of  nutrition  is 
much  greater.  In  the  most  severe  cases  there  is  also  a  palpable 
tumor  at  the  pylorus.  This  tumor  is  usually  small  in  comparison 
with  that  felt  in  hypertrophic  stenosis  of  the  pylorus.  It  feels 
longer  and  thinner.  In  typical  cases  it  can  be  felt  to  appear  and 
disappear  under  the  finger  as  the  pylorus  contracts  and  relaxes,  in 
contradistinction  to  the  tumor  in  hypertrophic  stenosis  which  does 
not  change. 

Roentgenograms,  taken  after  a  bismuth  meal,  show  very  marked 
interference  with  the  passage  of  the  stomach  contents  into  the 
duodenum.  They  seldom  show,  however,  such  complete  and 
permanent  obstruction  at  the  pylorus  as  is  commonly  present  in 
hypertrophic  stenosis. 

DIAGNOSIS 

The  differential  diagnosis  between  spasm  and  hypertrophic 
stenosis  of  the  pylorus  is  described  in  the  discussion  of  the  latter 
condition.  The  points  of  the  greatest  value  in  diagnosing  spasm  of 
the  pylorus  from  indigestion  with  vomiting  are  the  absence  of 
evidences  of  indigestion  in  the  vomitus,  the  explosive,  projectile 
vomiting,  the  presence  of  visible  peristalsis  and  of  a  palpable 
tumor,  and  the  delay  in  the  opening  of  the  pylorus,  shown  in 
Roentgenograms  taken  after  a  bismuth  meal.  In  habitual  vomit- 
ing, the  other  condition  with  which  spasm  of  the  pylorus  may  be 
confused,  the  general  condition  of  the  baby  is  unaffected,  the  vomit- 
ing varies  with  the  position  and  activity  of  the  baby  and  is  never 
projectile,  the  stools  are  sufficient  in  amount  and  fecal  in  character, 
there  is  no  visible  peristalsis  and,  of  course,  no  palpable  tumor. 


TREATMENT  257 

PROGNOSIS 

The  prognosis  is,  in  general,  good.  The  symptoms  persist  for 
many  weeks  or  months  in  the  severe  cases,  however,  even  under 
the  most  careful  treatment.  Some  of  the  most  severe  cases  are  not 
amenable  to  medical  treatment  and  will  die  unless  operated  upon. 

TREATMENT 

The  most  important  part  of  the  treatment  of  pyloric  spasm  is 
regulation  of  the  diet.  The  best  food  is  good  human  milk.  If  this 
is  vomited,  it  is  well  to  remove  a  part  of  the  cream  and  add  lime 
water.  The  next  best  food  is  some  modification  of  cow's  milk.  It 
is  advisable  to  keep  the  percentage  of  fat  low,  because  fat  tends  to 
delay  the  emptying  of  the  stomach.  A  percentage  of  0.50  is  none 
too  low  in  the  beginning.  It  is  also  advisable  to  give  as  large  a  pro- 
portion as  possible  of  the  protein  in  the  form  of  the  whey  proteins, 
because  they  are  not  coagulated  by  rennin  and,  therefore,  easily 
pass  the  pylorus.  Plain  whey  is  very  useful  in  some  instances.  All 
the  measures  which  prevent  the  formation  of  large  casein  curds 
are  applicable  in  this  condition,  in  that  they  make  the  emptying 
of  the  stomach  less  difl&cult.  Carbohydrates,  which  leave  the  stom- 
ach readily  and  quickly,  can  usually  be  given  freely.  Lactose  is 
the  best  of  the  sugars  in  this  condition.  These  general  principles 
serve,  of  course,  only  as  a  basis  for  the  preparation  of  the  food, 
which  must  be  varied  to  suit  the  individual  baby. 

Clinically,  the  addition  of  an  alkali  to  the  food  is  of  considerable 
assistance  in  many  of  these  cases,  while  in  others  it  apparently  does 
no  good.  It  presumably  does  good  by  delajning  the  coagulation 
of  the  casein  by  rennin  and  thus  favoring  the  passage  of  the  liquid 
milk  through  the  pylorus.  It  should  be  added  in  relation  to  the 
milk  and  cream  in  the  mixture,  not  in  relation  to  the  total  quan- 
tity or  to  the  whey  in  the  mixture.  It  is  well  to  add  lime  water 
at  first  to  the  amount  of  50%  of  the  milk  and  cream.  If  some 
other  alkali  is  used,  a  corresponding  amount  should  be  given. 
Cowie  ^  believes  that  the  action  of  the  alkali  is  dependent  on  the 
degree  of  the  acidity  of  the  gastric  contents  and  the  effect  of  the 
change  of  the  reaction  of  the  gastric  contents  on  the  pyloric  reflex. 
If  his  explanation  is  correct,  it  is  possible  to  exaggerate  the  condi- 
tion by  giving  alkaUs,  and  in  any  case  the  alkalis  must  be  added 
very  carefully,  preferably  on  the  basis  of  the  findings  obtained  by 
the  analysis  of  the  gastric  acidity. 

*  American  Journal  of  Diseases  of  Children,  1913,  v,  225. 


258  TREATMENT 

There  is  much  difference  of  opinion  as  to  whether  the  food  should 
be  given  at  short  or  long  intervals  and  as  to  the  quantity  which 
should  be  given  at  a  feeding.  The  most  rational  way  of  regulating 
the  interval  between  feedings  is  to  determine  how  long  it  takes  the 
stomach  to  empty  itself  in  the  individual  case  and  to  make  the  in- 
tervals somewhat  longer  than  this.  In  general,  it  is  probably  bet- 
ter to  give  small  amounts  at  a  feeding,  although  there  are  many 
exceptions  to  this  rule. 

Daily  lavage  with  plain  water  or  a  weak  solution  of  bicarbonate 
of  soda  is  of  assistance  in  most  cases,  although  some  authors  think 
that  it  tends  to  keep  up  the  spasm.  Warm  applications  to  the 
epigastrium  for  one-half  an  hour  before  and  one-half  an  hour  after 
feeding  are  sometimes  of  assistance.  Flaxseed  meal  poultices  are 
the  most  efficacious.  Minute  doses  of  some  preparation  of  opium — 
^-  d-y  To  of  ^  minim  of  the  tincture — given  a  short  time  before 
feedings  sometimes  seem  to  diminish  the  spasm.  Atropine  and 
cocaine  have  also  been  used  for  the  same  purpose.  It  is  also  im- 
portant to  keep  these  babies  very  quiet,  especially  immediately 
after  feeding. 

Rosenhaupt  ^  claims  good  results  in  this  condition  from  rectal 
irrigations  of  salt  solution,  basing  his  treatment  on  Engel's  state- 
ment that  the  cause  of  the  trouble  is  gastrosuccorrhcea  and  on 
Benczur's  experiments  which  show  that  in  animals  rectal  injec- 
tions of  salt  solution  diminish  the  secretion  of  gastric  juice.  He 
obtained  favorable  results  in  all  but  one  case,  but  does  not  state 
how  many  patients  he  treated.  Rosenstern  claims  good  results 
in  four  cases  from  the  rectal  instillation  of  from  250  c.  c.  to  400  c.  c. 
of  Ringer's  solution  daily.  This  method  of  treatment  is,  however, 
so  new  that  it  must  be  regarded  as  still  sub  judice. 

Surgical  intervention  for  the  relief  of  pyloric  spasm  is  seldom 
necessary.  Experience  has  shown,  however,  that  babies  sometimes 
die  of  this  condition  under  medical  treatment.  When,  therefore, 
a  baby  is  steadily  going  down  hill  under  medical  treatment,  sur- 
gical intervention  is  indicated.  An  operation  will  relieve  the  S3anp- 
toms  and  save  the  baby's  life,  just  as  it  does  in  hypertrophic 
stenosis  of  the  pylorus.  The  spasm  will  cease  in  time.  When  this 
happens  and  there  is  no  longer  any  obstruction  to  the  passage  of 
the  food  through  the  pylorus,  the  food  will  then  pass  through  the 
pylorus,  the  opening  from  the  stomach  into  the  bowel  will  close 
and  the  normal  conditions  be  reestabhshed. 

1  Deutsche  med.  Woch.,  1909,  xxxv,  1789. 


CHAPTER  XXI 
HYPERTROPHIC  STENOSIS  OF  THE  PYLORUS 

The  pathological  condition  in  this  disease  is  an  overgrowth  of 
the  circular  muscular  fibers  of  the  pylorus.  The  longitudinal  fibres 
are  little,  if  at  all,  involved.  The  normal  longitudinal  folds  of  the 
mucous  membrane  lining  the  pylorus  are  hypertrophied.  There  is 
at  times  a  slight  increase  in  the  connective  tissue  of  the  submucosa, 
The  opening  of  the  pylorus,  which  normally  admits  a  No.  21  sound. 
French  scale,  is  narrowed  by  the  thickened  muscle  and  the  folds 
of  mucous  membrane  until,  in  well-marked  cases,  it  will  not  allow 
the  passage  of  even  a  fine  probe.  In  extreme  cases  it  is  impossible 
to  force  water  through  the  pyloric  opening.  The  tumor  is  usually 
about  the  size  and  shape  of  a  dressed  olive. 

There  is  more  or  less  hypertrophy  of  the  muscles  of  the  stomach 
wall  in  all  cases.  There  is  also  almost  always  some  enlargement 
of  the  stomach.  This  enlargement  of  the  stomach  may  be  consid- 
erable in  advanced  cases.  The  oesophagus  is  also  sometimes  some- 
what dilated.  The  intestines  are  collapsed  and  empty.  There  are 
no  evidences  of  inflammation  and  in  most  instances  there  is  no 
catarrhal  condition  of  the  gastric  mucosa.  There  is  general  wast- 
ing of  all  the  organs  and  tissues  as  the  result  of  starvation. 

The  muscular  hypertrophy  is  sufficient  after  a  few  weeks,  in  the 
great  majority  of  instances,  to  practically  occlude  the  pyloric  ori- 
fice and  to  almost  or  entirely  prevent  the  passage  of  the  gastric 
contents  into  the  duodenum.  It  is  probable  that  in  other  instances 
the  hypertrophy  is  less  marked  and  the  narrowing  of  the  lumen 
consequently  less  extreme.  It  is  presumable  that  this  hyper- 
trophy is  at  the  bottom  of  some  of  the  cases  of  pyloric  obstruction 
which  develop  in  late  childhood  and  adult  life.  It  is  possible  that 
when  the  overgrowth  is  slight  it  may  be  neutralized  by  the  growth 
of  the  parts  with  age.  The  facts  that  the  conditions  found  at  au- 
topsy in  one  instance  some  months  after  gastroenterostomy  for  a 
complete  obstruction  were  the  same  as  at  the  time  of  the  oper- 
ation ^  and  that  Roentgenograms  show  that  the  food  continues  to 
pass  through  the  new  stoma  for  years  after  the  operation  indicate, 

*  Morse,  Murphy  and  Wolbach:  Boston  Medical  and  Sui^cal  Journal, 
1908,  clviii,  480. 

259 


260  SYMPTOMATOLOGY 

however,  that  there  is  no  dimmution  in  the  hypertrophy  in  those 
instances  in  which  it  is  marked. 


ETIOLOGY 

The  etiology  of  this  condition  is  obscure  and  has  given  rise  to 
much  discussion.  The  weight  of  the  evidence,  however,  is  in  favor 
of  the  view  that  it  is  a  congenital  abnormality  rather  than  the 
result  of  muscular  spasm,  acting  either  before  or  after  birth. 
There  is  no  doubt,  on  the  other  hand,  that  in  many  instances  in 
which  the  stenosis  is  not  complete,  the  symptoms  are  exaggerated 
by  spasm. 

Hypertrophic  stenosis  of  the  pylorus  occurs  more  frequently  in 
boys  than  in  girls.  It  is  just  as  common  in  breast-fed  babies  as  in 
the  artificially-fed. 

SYMPTOMATOLOGY 

The  first  symptom  is  vomiting.  It  may  begin  in  the  first  few 
days  of  life,  but  ordinarily  does  not  appear  before  the  beginning 
of  the  second  week.  It  seldom  develops  after  the  first  month. 
There  is  nothing  characteristic  about  the  vomiting  in  the  begin- 
ning. It  soon  becomes  forcible  and  explosive.  The  gastric  con- 
tents may  be  shot  out  of  the  mouth  to  a  distance  of  several  feet. 
The  vomiting  usually  occurs  soon  after  the  taking  of  food,  but  may 
occur  at  any  time,  sometimes  not  until  just  before  the  next  feeding. 
Two,  or  even  more  feedings,  are  sometimes  retained  and  expelled 
together.  The  whole  of  the  stomach  contents  is  usually  vomited 
at  one  time.  The  vomiting  is  in  most  instances  not  accompanied 
by  pain.  The  vomitus  consists  in  the  beginning  simply  of  the  food 
taken,  which  is  more  or  less  digested  according  to  the  interval 
which  has  elapsed  between  its  ingestion  and  the  vomiting.  Later 
on  it  often  contains  mucus,  but  never,  except  in  the  rarest  instances, 
bile.  There  is  nothing  characteristic  about  the  reaction  of  the  gas- 
tric contents.  The  baby  is  anxious  to  eat  again  immediately  after 
it  has  vomited,  unless  it  is  temporarily  exhausted  by  the  process. 
In  spite  of  the  frequent  vomiting,  the  tongue  is  clean  and  the 
breath  sweet. 

Constipation  quickly  develops,  because  so  little  of  the  food' 
passes  through  the  pylorus  into  the  intestine  that  there  is  but  lit- 
tle residue  to  be  passed  out  of  the  bowels.  The  stools  are  small 
and,  being  composed  of  the  same  materials  as  the  meconium,  re- 
semble it  in  appearance. 

Loss  of  weight  is  a  constant  symptom.    It  is  progressive  and  be- 


PHYSICAL  EXAMINATION  261 

comes  more  rapid  as  time  goes  on.  It  is  due,  of  course,  to  the 
lack  of  food  and  liquid  as  the  result  of  the  vomiting.  The  skin 
becomes  dry,  the  face  pinched  and  the  baby  soon  shows  all  the 
evidences  of  starvation. 


PHYSICAL  EXAMINATION 

The  abdomen  at  first  shows  nothing  abnormal  on  inspection. 
After  a  time,  however,  the  epigastrium  appears  full  when  food  is 
taken,  and  the  rest  of  the  abdomen  sunken.  When  there  is  dilata- 
tion of  the  stomach,  it  may  be  recognized  by  inspection  and  palpa- 
tion. Great  care  must  be  excercised  in  diagnosing  dilatation  of  the 
stomach,  however,  because  of  the  great  variation  in  the  normal 
position  of  this  organ.  Waves  of  peristalsis,  running  across  the 
stomach  from  left  to  right,  appear  soon  after  the  vomiting  becomes 
marked.  They  occur  only,  of  course,  when  the  stomach  has  some- 
thing in  it.  If  they  do  not  appear  soon  after  food  is  taken,  they  can 
often  be  ehcited  by  stroking  the  epigastrium,  flicking  it  with  a 
towel  wet  in  cold  water,  or  by  the  appUcation  of  a  piece  of  ice. 
They  are  usually  about  the  size  of  half  an  egg  and  run  very  slowly 
across  the  epigastrium.  Two,  or  even  three,  waves  are  sometimes 
visible  at  the  same  time. 

A  tumor  can  be  felt  in  most  instances.  It  is  usually  situated 
about  midway  between  the  tip  of  the  ensiform  and  the  navel  and 
between  one-half  an  inch  and  one  inch  to  the  right  of  the  median 
Une.  This  position  is,  however,  not  a  constant  one.  The  tumor  is 
not  infrequently  under  the  edge  of  the  liver.  It  ordinarily  feels 
much  like  a  dressed  oUve,  both  in  size  and  shape.  It  does  not  vary 
in  size.  It  may  be  mistaken  for  a  large  gland.  If  peristaltic  waves 
are  present,  the  tumor  will  often  be  found  where  they  disappear. 
The  tumor  may  be  felt  at  any  time.  It  is  usually  easier  to  find  it 
when  the  stomach  is  empty  than  when  it  is  full,  but  the  opposite  is 
sometimes  the  case.  If  there  is  any  reason  to  suspect  the  presence 
of  a  pyloric  tumor,  the  abdomen  should  always  be  examined  with 
the  stomach  both  full  and  empty.  This  is  easily  accompUshed  by 
having  the  baby  fed  or  with  the  aid  of  a  stomach-tube.  The  tu- 
mor is  most  easily  felt  during  the  relaxation  after  vomiting.  An 
anaesthetic  may  be  used  to  produce  relaxation,  if  necessary. 

Under  normal  conditions.  Roentgenograms  of  the  stomach, 
taken  immediately  after  a  meal  containing  bismuth,  show  food 
passing  through  the  pylorus  into  the  duodenum.  Roentgenograms 
taken  at  intervals  afterwards  show  that  the  stomach  is  empty 
in  most  instances  in  from   two   to   four   hours.     When  there 


262  DIAGNOSIS 

is  stenosis  of  the  pylorus,  Roentgenograms  taken  at  once  show 
nothing  passing  through  the  pylorus.  Those  taken  afterwards 
show  that  Uttle  or  nothing  passes  through  the  pylorus  and  show 
bismuth  in  the  stomach  for  many  hours,  unless  it  has  been  vomited. 
It  is  impossible  to  pass  a  duodenal  catheter,  if  there  is  stenosis. 
In  many  instances  in  which  the  muscular  hypertrophy  is  not 
extreme,  and  presumably  in  most  cases  in  the  beginning,  the  nar- 
rowing of  the  pyloric  canal  which  is  caused  by  the  mechanical  ob- 
struction of  the  tumor  is  increased  by  spasm  of  the  muscle.  It  is 
the  spasm  of  the  muscle  which  accounts  for  the  variation  in  the 
severity,  or  even  intermittency,  of  the  symptoms  in  many  cases 
and  for  the  sudden  onset  of  severe  symptoms  in  others.  When 
a  part  of  the  obstruction  is  due  to  spasm,  everything  may  be  vom- 
ited for  a  time  and  then,  when  the  spasm  ceases,  a  considerable  part 
of  the  food  will  be  retained.  The  character  of  the  stools  will  vary 
at  the  same  time,  resembling  meconium  when  the  spasm  is  marked 
and  being  fecal  when  it  diminishes. 

DIAGNOSIS 

The  diagnosis  of  a  well-marked  case  of  hypertrophic  stenosis  of 
the  pylorus  is  very  easy.  The  combination  of  vomiting,  beginning 
within  a  few  days  or  weeks  after  birth,  increasing  steadily  in  se- 
verity, becoming  projectile  in  character  and  having  no  relation 
to  the  character  of  the  food,  marked  constipation  with  meconium- 
like  stools,  visible  gastric  peristalsis  and  a  palpable  tumor,  not 
varying  in  size,  in  the  region  of  the  pylorus,  is  pathognomonic.  Al- 
though the  tumor  at  the  pylorus  can  almost  always  be  found  if 
carefully  sought  for  under  the  proper  conditions,  a  positive  diagno- 
sis of  this  condition  is  justifiable,  if  the  other  symptoms  and  signs 
are  present,  even  if  the  tumor  cannot  be  made  out.  The  diagnosis 
should  always  be  confirmed,  however,  if  possible,  by  Roentgen- 
ograms taken  after  a  bismuth  meal  and  the  duodenal  catheter. 

The  diagnosis  between  hypertrophic  stenosis  of  the  pylorus  and 
spasm  of  the  pylorus  is,  however,  at  times  a  very  difficult  one.  The 
onset  of  the  symptoms  is  the  same  in  both,  the  vomiting  is  explo- 
sive in  both  and  there  is  visible  peristalsis  in  both.  Constipation 
and  loss  of  weight  are  common  to  both.  There  is  sometimes  a  pal- 
pable tumor  in  spasm;  the  tumor  is  sometimes  not  palpable  in  hy- 
pertrophic stenosis.  In  spite  of  the  similarity  of  the  S5Tiiptoms  of 
the  two  diseases,  there  should  be  little  difficulty  in  distinguishing 
the  marked  cases  of  hypertrophic  stenosis  from  those  of  spasm,  be- 
cause the  constipation  is  never  so  marked  or  persistent  in  spasm  as 
in  stenosis  and  because  the  tumor  in  spasm  is  small  and  cord-like, 


DIAGNOSIS  263 

not  large  and  hard  as  in  hypertrophic. stenosis.  Variation  in  the 
size  of  the  tumor  during  examination  is  practically  positive  proof 
that  the  condition  is  one  of  spasm,  not  of  hypertrophy.  The  dif- 
ficulty in  diagnosis  comes  between  the  severe  cases  of  spasm  and 
the  mild  cases  of  hypertrophic  stenosis,  because  the  difference  in 
the  symptomatology  of  the  two  diseases  is  entirely  in  the  degree, 
not  in  the  kind,  of  the  symptoms. 

It  is  impossible  in  many  instances  to  make  at  first  a  positive 
diagnosis  between  these  two  conditions.  If  the  baby  is  breast-fed, 
the  chances  are  much  in  favor  of  h)T)ertrophic  stenosis,  because 
spasm  is  very  unusual  in  the  breast-fed  while  hypertrophic  steno- 
sis is  equally  common  in  the  breast-fed  and  in  the  artificially-fed. 
If  the  baby  is  artificially-fed,  the  chances  are  even,  although  if  the 
feeding  has  been  very  irrational,  spasm  is  a  httle  the  more  probable. 
The  absence  of  a  palpable  tumor  is  strong  evidence  against  hyper- 
trophic stenosis,  but  does  not  positively  exclude  it,  because  a  good- 
sized  tumor  has  sometimes  been  found  at  operation  when  none  was 
felt  before.  It  is  never  safe  to  conclude  that  there  is  no  tumor, 
however,  unless  the  abdomen  has  been  examined  with  the  stomach 
both  full  and  empty,  and  with  the  abdominal  walls  relaxed,  if  nec- 
essary under  an  anaesthetic.  If  no  tumor  is  felt  under  these  con- 
ditions, an  almost  positive  diagnosis  of  spasm  is  justified.  Exam- 
ination of  the  gastric  contents  is  of  little  or  no  assistance,  because 
there  are  very  few  reliable  data  as  to  the  chemistry  of  the  gastric 
contents  in  these  conditions  and  what  few  data  there  are  are  con- 
tradictory. An  excessive  hyperacidity  perhaps  counts  a  little, 
however,  in  favor  of  spasm.  Dilatation  of  the  stomach  seldom  de- 
velops in  simple  spasm  of  the  pylorus  and,  if  it  does,  is  always 
slight.  It  develops  in  a  certain  proportion  of  the  cases  of  hyper- 
trophic stenosis,  but  is  seldom  extreme.  The  presence  of  dilata- 
tion is,  therefore,  in  favor  of  hypertrophic  stenosis  and  against 
spasm.  Its  absence  does  not  count  at  all  in  favor  of  spasm.  Dilata- 
tion of  the  stomach,  unless  extreme,  is  very  difficult  of  demonstra- 
tion in  infancy.  Too  much  importance  must  not  be  attached, 
therefore,  to  what  are  apparently  sUght  degrees  of  dilatation. 
Rapid  improvement  under  medical  treatment  and  regulation  of  the 
diet  is  strong  evidence  in  favor  of  spasm,  but  does  not  positively 
exclude  a  mild  degree  of  hypertrophic  stenosis  compHcated  by 
spasm.  The  most  important  points  in  favor  of  spasm  in  doubtful 
cases  are,  therefore,  the  absence  of  a  palpable  tumor  or,  if  a  timior 
is  present,  its  cord-like  feel,  the  presence  of  intermittent  contrac- 
tion and  relaxation  of  the  tumor,  and  rapid  improvement  under 
medical  treatment  and  regulation  of  the  diet. 


264  DIAGNOSIS 

Roentgenograms  are  of  less  value  in  the  diagnosis  between  severe 
cases  of  spasm  of  the  pylorus  and  mild  cases  of  stenosis  than  be- 
tween stenosis  and  other  conditions,  because  there  is  obstruction 
at  the  pylorus  and  therefore  delay  both  in  the  opening  of  the  py- 
lorus and  in  the  emptying  of  the  stomach  in  both  cases. 

When  hypertrophic  stenosis  of  the  pylorus  of  slight  or  mod- 
erate degree  is  complicated  by  spasm  of  the  pylorus,  the  varia- 
tion in  the  severity  of  the  symptoms  and  the  temporary  response 
to  medical  treatment  and  regulation  of  the  diet  are  often  most 
confusing.  When  there  is  hypertrophy  there  is,  however,  almost 
always,  in  spite  of  the  variation  in  the  symptoms,  a  progres- 
sive increase  in  their  severity.  The  presence  of  a  tumor  which 
does  not  change  in  size  or  shape  is  conclusive  proof  that  there  is 
an  organic  stenosis,  no  matter  how  much  the  other  symptoms 
may  vary. 

The  diagnosis  between  hypertrophic  stenosis  of  the  pylorus  and 
indigestion  with  vomiting  is  a  comparatively  simple  one.  Indiges- 
tion seldom  occurs  in  the  breast-fed,  but  develops,  as  a  rule,  after  a 
longer  or  shorter  period  of  bad  artificial  feeding.  Vomiting  is  the 
most  prominent  symptom,  occurs  without  any  definite  relation  to 
the  time  of  taking  food,  and  is  never  explosive.  The  amount  of  the 
vomitus  rarely  exceeds  that  of  the  food  taken  at  the  last  feeding 
and  the  vomitus  usually  shows  evidence  of  disturbance  of  the 
gastric  digestion.  The  stools  often  present  the  evidences  of  an 
associated  intestinal  indigestion,  but  constipation,  as  the  result 
of  the  reduction  in  the  amount  of  food  retained,  is  not  uncommon. 
The  stools  are,  however,  never  of  the  starvation  type,  but  show  by 
their  characteristics  that  food  is  passing  from  the  stomach  into  the 
bowel.  There  is  never  any  visible  peristalsis  and,  of  course,  no 
tumor  to  be  felt  at  the  pylorus.  Roentgenograms  taken  after  a 
bismuth  meal  will  settle  the  diagnosis  at  once  in  doubtful  cases, 
because  the  food  begins  to  leave  the  stomach  inamediately  in  indi- 
gestion, while  nothing  passes  the  pylorus  for  a  long  time  when  there 
is  obstruction  from  a  pyloric  tumor. 

Another  condition  which  sometimes  suggests  hypertrophic 
stenosis  of  the  pylorus  is  habitual  vomiting.  In  this  condition  the 
baby  without  any  other  symptoms  of  indigestion  vomits  habit- 
ually. In  spite  of  the  vomiting,  it  nevertheless  has  stools  normal  in 
size  and  appearance  and  gains  steadily  in  weight.  These  points  are 
of  themselves  sufficient  to  rule  out  stenosis  of  the  pylorus.  Fur- 
ther points  in  which  the  symptomatology  of  this  condition  varies 
from  that  of  stenosis  are  that  the  vomiting  rarely  occurs  when  the 
baby  is  quiet  and  that  it  varies  with  the  amount  of  exertion  and  the 


PROGNOSIS  AND  TREATMENT  265 

position  of  the  baby.  The  vomiting  is  never  explosive  and  there  is 
no  visible  peristalsis  or  palpable  tumor.  The  vomiting  in  this  con- 
dition is  sometimes  due  to  an  excessive  amount  of  food,  but  more 
often,  probably,  to  the  lack  of  tone  or  imperfect  closure  of  the  car- 
diac orifice. 

PROGNOSIS  AND  TREATMENT 

The  prognosis  of  hypertrophic  stenosis  of  the  pylorus,  when  the 
obstruction  is  marked  and  due  wholly  or  chiefly  to  the  muscular 
hypertrophy,  is  hopeless  imder  medical  treatment.  Death  will 
surely  ensue  in  a  few  weeks  as  the  result  of  starvation.  These 
cases  can  be  saved,  however,  by  an  operation,  provided  the  opera- 
tion is  done  at  a  time  when  the  baby  is  able  to  stand  the  shock  of 
the  operation,  which  is  a  severe  one.  They  should  be  operated 
upon  as  soon  as  the  diagnosis  is  made.  Every  day  of  delay  mate- 
rially diminishes  their  chances  of  recovery.  The  best  operation  is 
the  spUtting  of  the  pylorus,  the  so-called  Rammstedt  operation. 
This  is  far  preferable  to  posterior  gastroenterostomy  or  the  modi- 
fied pyloroplasty  recommended  by  Dr.  Keef  e.  ^  Both  of  these  opera- 
tions require  especial  skill  and  should  be  performed  only  by  sur- 
geons who  are  in  the  habit  of  operating  on  infants  or  have  had  much 
experience  in  operating  on  small  animals.  The  Rammstedt  opera- 
tion can  be  easily  performed,  however,  by  any  surgeon.  It  requires, 
moreover,  much  less  time  and  is  accompanied  by  much  less  shock. 

The  medical  treatment  of  these  cases  both  before  and  after 
operation  is  of  considerable  importance.  They  should  be  given 
salt  solution  by  enema  or  seepage,  and  if  necessary  subcutaneously, 
before  the  operation.  The  stomach  should  be  washed  out  just 
before  the  operation.  Salt  solution  should  be  given  in  the  same 
ways  after  the  operation.  Feeding  should  be  begun  as  soon  as  the 
baby  has  thoroughly  recovered  from  the  effects  of  the  anaesthetic. 
The  best  food  is  human  milk,  diluted  at  first  with  three  parts  of 
water,  the  strength  being  quickly  increased .  If  this  is  not  available, 
the  next  best  thing  is  whey.  This  should  be  gradually  strengthened 
by  the  addition  of  gravity  cream  to  give  0.25%  of  fat,  0.50%  of  fat 
and  1.00%  of  fat.  The  regulation  of  the  food  from  this  time  on  is 
usually  comparatively  simple  and  along  the  general  lines  of  infant 
feeding.  It  is  advisable  to  begin  to  feed  with  one  drachm  (5  c.  c.) 
every  hour,  increasing  the  amount  and  lengthening  the  interval 
between  feedings  as  rapidly  as  possible.  There  is  very  little  danger 
of  overloading  the  stomach,  because  there  is  no  obstacle  to  the 
passage  of  the  food  from  the  stomach  into  the  intestine.     The 

1  Boston  Med.  and  Surg.  Journal,  1913,  cbdx,  318. 


266  PROGNOSIS 

difficulty  lies  in  the  intestine,  which  has  not  been  in  the  habit  of 
receiving  large  amounts  of  food.  If  the  intestine  is  contracted,  as  it 
is  in  most  cases  which  are  operated  on  late  in  the  disease,  it  is 
unable  to  take  care  of  much  food.  If  the  operation  is  performed 
early,  before  contraction  of  the  intestine  has  taken  place,  large 
amounts  of  food  can  generally  be  given. 

The  future  development  of  babies  in  whom  a  posterior  gastroen- 
terostomy has  been  successfully  done  for  hypertrophic  stenosis  of 
the  pylorus  is  normal  and  their  processes  of  digestion  and  absorp- 
tion are  not  impaired.^  The  tumor  does  not  diminish  in  size,  how- 
ever, the  lumen  of  the  pylorus  is  not  restored  and  the  food  con- 
tinues to  pass  through  the  gastroenterostomy  opening.^  The  fu- 
ture development  of  babies  on  whom  the  Rammstedt  operation 
has  been  performed  is  also  normal.  The  food  continues  to  pass 
freely  through  the  pylorus  and  in  one  instance  it  was  found  five 
months  after  the  operation  that  the  pyloric  tumor  had  disap- 
peared.^ 

When  the  condition  is  one  of  partial  stenosis  complicated  by 
spasm,  the  treatment  is  primarily  that  of  spasm  of  the  pylorus. 
The  methods  to  be  employed  are  described  in  the  treatment  of  this 
condition.  It  is  wiser,  however,  to  operate  in  this  condition  also, 
unless  the  symptoms  are  quickly  and  almost  entirely  relieved. 
Unless  this  is  done,  the  nutrition  of  the  infant  is  certain  to  be 
materially  impaired  and  its  development  retarded.  There  is  but 
little  reason  to  anticipate,  moreover,  that  the  organic  obstruction 
will  diminish  in  the  future.  It  is  also  not  improbable  that  a  certain 
proportion  of  the  cases  of  benign  obstruction  at  the  pylorus  which 
develop  in  later  childhood  and  early  adult  life  are  the  result  of  mild 
degrees  of  infantile  hypertrophic  stenosis. 

1  Scudder:  Surgery,  Gynecology  and  Obstetrics,  1910,  xi,  275;  Talbot: 
Boston  Medical  and  Surgical  Journal,  1910,  clxi,  782,  and  1910,  clxii,  490, 

*  Scudder*  Surgery,  Gynecology  and  Obstetrics,  1910,  xi,  275;  Morse, 
Murphy  and  Wolbach:  Boston  Medical  and  Surgical  Journal,  1908,  clviii, 
480;  Koplik:  American  Journal  Medical  Sciences,  1908,  cxxxvi,  i. 

'  Rachford:  Archives  of  Pediatrics,  1917,  xxxiv,  803. 


CHAPTER  XXn 
NERVOUS  DISTURBANCES  OF  THE  DIGESTIVE  TRACT 

S3aiiptoms  pointing  to  disturbance  in  the  digestive  tract  develop 
not  very  infrequently  as  the  result  of  causes  or  conditions  acting 
directly  on  the  nervous  system.  The  sjmaptoms  referable  to  the 
digestive  tract  are  due  to  disturbance  of  the  functions  of  this  tract 
as  the  result  of  abnormal  influences  transmitted  to  it  from  the 
unduly  irritable  or  exhausted  nervous  centers.  The  most  char- 
acteristic symptoms  are  those  due  to  the  disturbance  of  the 
mechanical  functions  of  the  stomach  and  intestines.  When  the 
symptoms  are  due  to  disturbance  of  the  secretory  functions  of  the 
digestive  tract,  they  are  indistinguishable  from  those  due  to  dis- 
turbance of  these  functions  from  other  causes.  In  fact,  the  condi- 
tion is  then  an  indigestion.  Only  those  symptoms  due  to  dis- 
turbance of  the  mechanical  functions  will,  therefore,  be  described. 

The  most  common  of  the  causes  acting  through  the  nervous 
system  are  extremes  of  temperature,  whether  of  heat  or  cold,  more 
commonly  of  heat.  Diarrhea  is  a  more  conmion  result  than 
vomiting.  The  vomitus  consists  simply  of  the  contents  of  the 
stomach  and  shows  no  evidences  of  indigestion.  The  diarrhea  is 
due  to  increased  intestinal  peristalsis.  The  intestinal  contents  are, 
in  consequence,  hurried  through  the  bowels.  The  stools  are, 
therefore,  normal  in  every  way,  except  that  they  are  increased  in 
number  and  diminished  in  consistency.  Excitement  and  fear  may 
have  the  same  effect  as  extremes  of  temperature.  The  body 
temperature  is  not  altered  in  these  cases.  There  may,  however,  be 
a  certain  amount  of  abdominal  discomfort  and  general  constitu- 
tional depression. 

It  is  conceivable  that  improper  and  indigestible  food,  acting  sim- 
ply as  a  foreign  body,  may,  through  irritation  of  the  stomach  and 
intestines,  reflexly  cause  vomiting  and  diarrhea  without  producing 
any  disturbance  of  the  digestive  functions.  If  this  occurs,  it  is, 
however,  very  uncommon.  In  such  instances  the  vomitus  and 
stools  will  contain  the  food  which  is  the  cause  of  the  symptoms. 

The  primary  cause  of  many  of  the  more  chronic  disturbances  of 
digestion  is  some  error  in  the  infant's  care  and  routine,  which 
results  in  over-excitement  and  exhaustion  of  the  nervous  system, 

267 


268    NERVOUS  DISTURBANCES  OF  DIGESTIVE  TRACT 

rather  than  improper  food.  Constant  attention,  noisy  surround- 
ings, lack  of  rest  and  sleep  will  often  be  found  to  be  at  the  bottom 
of  intractable  cases  of  indigestion  in  infancy.  No  change  in  the 
diet  will  benefit  them  in  any  way,  but  they  will  begin  to  improve 
at  once  when  the  undue  strain  on  the  nervous  system  is  removed. 

TREATMENT 

The  first  element  in  the  treatment  of  these  disturbances  of  the 
digestive  tract  due  to  causes  acting  through  the  nervous  system  is 
the  removal  of  the  cause.  Recovery  is  usually  prompt,  when  this 
is  removed.  It  is  also  wise  to  omit  one  or  two  feedings  and  then  to 
give  the  usual  food  weakened  for  one  or  two  days.  If  the  baby  is 
on  the  breast,  the  duration  of  the  nursings  should  be  shortened  and 
boiled  water  given  before  or  during  the  nursing  in  order  to  dilute 
the  milk.  If  the  baby  is  taking  an  artificial  food,  it  should  be 
diluted  with  water.  If  the  baby  is  on  a  mixed  diet,  the  less  easily 
digestible  articles  should  be  omitted. 

If  the  cause  of  the  trouble  is  indigestible  food,  it  is  best  to  give  a 
laxative,  such  as  milk  of  magnesia  or  phosphate  of  soda,  to  hurry  it 
out  of  the  bowels  before  it  can  set  up  a  disturbance  of  the  digestion. 
A  laxative  is  not  necessary,  except  when  improper  food  is  the  cause. 

If  improper  food  is  not  the  cause  of  the  trouble  and  the  baby  is 
having  a  large  number  of  loose  stools,  normal  in  other  ways,  it  is 
allowable  to  diminish  the  excessive  peristalsis  by  giving  paregoric  in 
doses  of  from  five  to  twenty  drops  every  two  or  four  hours,  accord- 
ing to  the  age  of  the  child  and  the  severity  of  the  symptoms. 


CHAPTER  XXin 
DISTURBANCES  OF  DIGESTION 

Disturbance  of  the  digestion  may  be  caused  by  an  excess  of  an 
otherwise  suitable  food,  by  a  too  rich  but  otherwise  well-balanced 
food  and  by  foods  containing  an  excessive  amount  of  one  or  of 
several  of  the  food  elements.  It  may  also  be  caused  indirectly  by 
other  diseases  or  by  any  extraneous  causes  which  weaken  the  gen- 
eral resistance  or  diminish  the  digestive  powers.  The  disturb- 
ance may  be  either  acute  or  chronic.  The  pathological  changes  in 
the  gastroenteric  tract  are  insignificant.  In  many  instances  there 
are  no  macroscopic  changes  beyond  thinning  of  the  intestinal  wall. 
In  others  there  is  reddening  of  the  surface  and  an  excessive  secre- 
tion of  mucus,  while  in  a  few  there  is  a  desquamation  of  the  super- 
ficial epithelium.  The  microscopic  changes  are  sHght  and  unim- 
portant. In  the  more  chronic  cases  there  is  a  general  wasting  of 
all  the  tissues  of  the  body  and  in  both  the  acute  and  chronic  cases 
there  may  be  degenerative  changes,  frequently  fatty,  in  the  paren- 
chymatous organs.  The  important  changes  are  in  the  metabolic 
processes  of  the  body.  These  are  not  recognizable  pathologically. 
They  are  at  present  imperfectly  understood.  They  vary  accord- 
ing to  which  of  the  food  elements  is  the  cause  of  the  indigestion. 

Disturbances  of  the  digestion  are  much  less  common  in  the 
breast-fed  than  in  the  artificially-fed.  The  symptoms  are  also,  as 
a  rule,  less  severe.  All  disturbances  of  the  digestion,  whatever 
their  cause,  have  many  symptoms  in  common.  The  other  symp- 
toms vary  in  accordance  with  the  food  element  which  is  at  the 
bottom  of  the  disturbance.  Disturbances  of  the  digestion  due  to 
an  excess  of  fat  are  likely  to  be  more  serious  and  more  lasting  than 
those  due  to  the  other  food  elements.  Those  due  to  an  excess  of 
sugar  are  more  often  acute  and  more  often  rapidly  fatal.  Those 
due  to  an  excess  of  protein  are  apparently  less  frequent  and  less 
serious  than  those  due  to  the  other  food  elements.  It  must  be  re- 
membered in  this  connection,  however,  that  this  apparent  infre- 
quency  may  be  due  to  failure  to  recognize  the  symptoms  and  that 
the  protein  may  really  be  at  fault  when  the  blame  is  attached  to  one 
of  the  other  elements. 

Simple  disturbances  of  the  digestion  may  be  associated  with 

269 


270  DISTURBANCES  OF  DIGESTION 

fermentation  of  the  improperly  digested  intestinal  contents  as  the 
result  of  bacterial  activity.  It  is  probable,  in  fact,  that  there  is 
more  or  less  fermentation  in  almost  every  case.  When  these  fer- 
mentative processes  are  marked  they  often  predominate  the  pic- 
ture and  the  condition  is  then  spoken  of  as  indigestion  with  fer- 
mentation. The  borderline  between  indigestion  with  bacterial 
fermentation  and  without  it  is,  however,  a  very  indefinite  one.  In 
many  instances  it  is,  therefore,  impossible  to  determine  in  which 
class  a  given  case  belongs. 

The  following  classification  will  be  adopted  in  discussing  the 
disturbances  of  digestion: 

Indigestion. 

1.  Indigestion  from  an  excess  of  food. 

2.  Indigestion  from  an  excess  of  an  individual  food  element. 

a.  Fat 

b.  Carbohydrates 

c.  Protein 

d.  Salts. 

3.  Indigestion  with  fermentation. 

INDIGESTION   FROM   AN   EXCESS   OF   FOOD 

Breast-Milk. — Indigestion  from  an  excessive  amount  of  breast- 
milk  is  comparatively  uncommon,  because  of  the  fact  that  Nature 
tends  to  accommodate  the  supply  of  milk  to  the  demand  and  be- 
cause, if  an  excessive  amount  is  taken,  the  baby  is  very  likely  to 
regurgitate  it  before  it  has  had  time  to  cause  any  disturbance  of  the 
digestion.  Indigestion  from  an  excessively  rich  breast-milk  is  also 
somewhat  uncommon. 

The  main  symptoms  of  indigestion  from  an  excessive  amount  of 
breast-milk  or  an  excessively  strong  breast-milk  are  vomiting,  an 
increased  number  of  stools,  failure  to  gain  properly  in  weight,  flat- 
ulence and  coUc.  The  babies  are,  as  a  rule,  somewhat  fussy  and 
do  not  sleep  well.  The  symptoms  are  seldom  very  marked.  When 
the  difiiculty  is  in  the  strength  of  the  milk,  they  are  very  likely  to 
lose  their  appetites.  There  is  nothing  characteristic  about  the 
vomitus.  The  stools  usually  contain  fat  curds  and  more  or  less 
mucus. 

The  condition  is  seldom  a  serious  one.  It  is  usually  easily  cor- 
rected. 

When  there  is  too  much  milk,  the  duration  of  the  nursing  must 
be  shortened.  How  much  it  should  be  shortened  can  usually  be 
determined  by  observation  of  the  baby's  symptoms.    More  accu- 


DISTURBANCES  OF  DIGESTION  271 

rate  results  can  be  obtained,  however,  by  weighing  the  baby  at 
intervals  during  the  nursing  and  stopping  the  nursing  when  the 
desired  amount  has  been  obtained.  The  failure  to  empty  the 
breasts  will  usually  quickly  bring  about  a  diminution  in  the  sup- 
ply of  milk.  The  mother  should  limit  her  ingestion  of  Uquids 
until  this  happens. 

When  the  breast-milk  is  excessively  rich,  the  intervals  between 
the  nursings  should  be  lengthened,  as  this  procedure  tends  to  di- 
minish the  amount  of  soUds  in  the  milk.  The  mother  should  eat 
more  simple  food  and  should  take  more  exercise.  Water  should 
be  given  at  the  time  of  the  nursing,  to  dilute  the  milk,  until  the 
strength  of  the  milk  has  become  normal.  The  amount  of  water 
to  be  given  depends  on  the  age  of  the  baby  and  the  strength  of  the 
milk.  It  may  be  given  with  a  spoon  or  in  a  bottle  before  or  during 
the  nursing,  or  through  a  dropper  introduced  into  the  mouth  be- 
side the  nipple  during  the  nursing.  It  is  almost  never  necessary  to 
wean  a  baby  because  of  an  excessively  strong  breast-milk. 

Artificial  Food. — Indigestion  from  an  artificial  food,  suitable 
in  every  way  except  that  too  much  of  it  is  given  or  that  it  is  too 
strong  in  all  its  percentages,  is  more  common  than  that  from  an 
excessive  amount  or  strength  of  breast-milk,  but  infinitely  less 
common  than  that  from  an  artificial  food  containing  an  excessive 
amount  of  one  or  two  of  the  food  elements. 

The  sjmaptoms  of  indigestion  from  an  excessive  amount  of  a 
suitable  food  or  of  too  strong  a  food  are  loss  of  appetite,  vomiting, 
an  excessive  number  of  stools,  flatulence  and  coUc,  and  failure  to 
gain  in,  or  loss  of,  weight.  The  babies  are,  as  a  rule,  fussy  and  ir- 
ritable and  sleep  poorly.  The  vomitus  is  not  characteristic,  but 
may  show  the  evidences  of  disturbance  of  the  digestion  of  any  or 
all  of  the  food  elements.  The  stools  are  also  not  characteristic, 
and  may  also  show  evidences  of  the  disturbance  of  the  digestion  of 
any  or  all  of  the  food  elements.  Evidences  of  disturbance  of  the 
digestion  of  fat  are,  perhaps,  the  most  common.  If  there  is  a  con- 
siderable amount  of  vomiting,  the  stools  may  be  constipated,  be- 
cause of  the  lack  of  sufficient  food  remnants  to  form  the  normal 
amount  of  feces. 

The  prognosis  of  indigestion  due  to  too  much  of  a  good  food  or 
to  an  excessively  rich,  but  otherwise  suitable,  food  is  usually  good. 
The  condition  usually  yields  readily  to  proper  treatment. 

The  treatment  consists  primarily  in  cutting  down  the  amount  of 
food  or  in  weakening  the  food.  It  is  advisable  in  most  instances  to 
weaken  the  food  considerably  more  than  enough  to  bring  it  to  the 
strength  which  would  be  suitable  for  the  average  normal  baby  of 


272  FAT  INDIGESTION 

the  given  age.  This  is  necessary,  because  the  digestive  processes 
have  usually  been  so  weakened  by  the  excessive  demands  upon 
them  that  they  are  unequal  to  meet  even  the  usual  demands. 
After  the  digestive  powers  have  recovered  themselves,  the  food 
can  gradually  be  strengthened.  It  is  usually  possible  to  straighten 
out  these  cases  without  a  wet-nurse. 

When  the  disturbance  is  an  acute  one  from  a  temporary  indis- 
cretion the  intestines  should  be  emptied  with  castor  oil  or  milk  of 
magnesia  and  all  food  stopped  for  from  twelve  to  twenty-four 
hours.  When  the  disturbance  is  a  chronic  one,  it  is  often  advisable 
to  begin  treatment  with  a  cathartic.  It  is  not  advisable  to  stop 
food,  even  for  a  time. 

INDIGESTION   FROM  AN  EXCESS   OF   FAT 

Breast-Milk. — Indigestion  from  an  excessive  amount  of  fat 
in  breast-milk  is  comparatively  uncommon.  The  percentage  of  fat 
is  seldom  very  high  and,  even  if  it  is,  babies  are  usually  able  to 
accommodate  themselves  to  it. 

The  main  symptoms  of  an  excessive  amount  of  fat  in  breast-milk 
are  loss  of  appetite,  vomiting  and  abnormal  stools,  with  more  or 
less  flatulence  and  colic.  Failure  to  gain  in  weight  or  a  moderate 
loss  of  weight  become  manifest  after  a  time.  The  symptoms  are, 
however,  seldom  serious.  There  is  usually  nothing  especially  ab- 
normal about  the  vomitus.  It  may,  however,  in  the  more  severe 
cases,  have  the  odor  of  butyric  and  other  fatty  acids.  The  stools 
contain  many  small,  soft  curds,  and  sometimes  have  an  oily  ap- 
pearance. They  are  more  acid  than  normal  and  may  cause  irrita- 
tion of  the  buttocks.  Soap  stools  are  most  imusual  as  the  result 
of  an  excess  of  fat  in  breast-milk. 

The  disturbance  caused  by  an  excessive  amount  of  fat  in  breast- 
milk  is  seldom  a  severe  one,  is  not  usually  of  long  duration  and  is 
ordinarily  easily  corrected. 

The  amount  of  fat  in  the  milk  can  sometimes  be  reduced  by  cut- 
ting down  the  fat  in  the  mother's  diet,  provided  she  has  been  eat- 
ing an  excessive  amount  of  it.  In  most  instances,  however,  it  will 
be  found  that  she  has  been  eating  too  much  in  general  rather  than 
too  much  fat.  Cutting  down  her  food  as  a  whole,  increasing  the 
amount  of  the  exercise  which  she  takes  and  getting  her  out  of  doors 
more  will  usually  promptly  bring  the  amount  of  fat  down  to  within 
normal  limits.  Shortening  the  duration  of  the  nursings  in  order 
that  the  baby  shall  not  entirely  empty  the  breast  is  of  some  advan- 
tage, because  the  fore-milk  contains  less  fat  than  the  last  milk  or 


FAT  INDIGESTION  273 

"strippings."  If  the  duration  of  the  nursings  is  shortened,  the  in- 
tervals between  the  nursings  must  also  be  diminished  in  order  that 
the  baby  may  get  enough  food.  Water  may  be  given  at  the  time 
of  the  nursing  in  order  to  diminish  the  percentage  of  fat  by  dilut- 
ing the  milk.  This  procedure  has  the  disadvantage,  however,  of 
diminishing  the  percentage  of  the  other  food  elements  as  well  as 
that  of  the  fat. 

Artificial  Food. — Indigestion  is  more  often  due  to  an  excess  of  fat 
in  artificial  food  than  to  an  excess  of  any  other  single  element.  The 
results  of  a  disturbance  of  the  digestion  from  an  excess  of  fat  are, 
moreover,  more  far-reaching,  more  lasting  and  more  difiicult  to 
correct  than  those  due  to  any  other  element. 

The  symptoms  are,  in  general,  loss  of  appetite,  flatulence  and 
colic,  vomiting,  abnormal  stools  and  failure  to  gain  in  weight  or, 
more  often,  progressive  loss  of  weight.  The  temperature  is  often 
elevated  in  acute  disturbances  of  the  digestion  caused  by  fat,  but 
is  likely  to  be  somewhat  subnormal  in  the  chronic  disturbances. 

The  vomitus  is  acid  in  reaction  and  has  a  strongly  acid  odor. 
This  odor  is  due  to  the  presence  of  butyric  and  other  fatty  acids. 
It  sometimes  has  a  creamy  appearance. 

The  most  conmion  abnormality  in  the  stools  is  the  presence  of 
many  small,  soft  curds.  These  are  often  accompanied  by  mucus. 
In  other  instances  the  stools  have  a  gray,  shiny  appearance.  When 
there  is  an  excess  of  neutral  fat,  the  stools  may  be  of  a  creamy  con- 
sistency and  are  often  about  the  color  of  cream.  In  other  instances 
they  look  like  curdled  milk.  More  often,  especially  in  the  chronic 
cases,  the  stools  are  gray,  or  grayish-yellow,  large,  hard  and  dry. 
They  may  sometimes  be  so  dry  as  to  be  crumbly.  The  fat  in  these 
stools  is  in  combination  with  calcium  and  magnesium  in  the  form 
of  soap,  that  is,  these  are  the  typical  "soap  stools."  In  other 
instances,  the  stools  are  watery,  strongly  acid,  and  cause  marked 
irritation  of  the  buttocks.  When  this  happens,  the  fat  is  in  com- 
bination with  the  alkaline  salts,  especially  sodium. 

When  there  is  an  acute  disturbance  of  the  digestion  as  the  re- 
sult of  an  excess  of  fat  in  the  food,  there  is  not  infrequently  a  high 
fever.  When  there  is  diarrhea,  as  there  often  is  in  the  acute  dis- 
turbances, there  is  not  only  an  excessive  loss  of  fat  in  the  stools, 
but  also  a  very  considerable  loss  of  alkaline  salts,  especially  sodium. 
A  relative  acidosis  results,  with  an  excess  of  ammonia  in  the  urine. 
The  symptoms  of  acid  intoxication  may  then  develop.  The  most 
characteristic  of  these  are  rapid  and  deep  respiration,  stupor  or 
restlessness,  and  cherry-red  lips. 

When  the  disturbance  of  the  digestion  is  a  chronic  one,  there  is 


274  FAT  INDIGESTION 

a  continuous  loss  of  magnesium  and  calcuim  in  the  stools  and  a 
consequent  disturbance  of  the  metabolism.  This  shows  itself  not 
only  in  a  chronic  disturbance  of  the.  nutrition  but  also  by  the  de- 
velopment of  the  manifestations  of  rickets  and  of  the  symptoms 
of  the  spasmophilic  diathesis.  The  manifestations  of  the  disturb- 
ances of  the  nutrition  as  the  result  of  the  disturbance  of  the  me- 
tabolism of  the  salts  may  become  most  marked,  so  that  the  babies 
come  to  present  the  characteristic  picture  of  "marasmus"  or  "in- 
fantile atrophy." 

The  prognosis  in  disturbances  of  the  digestion  due  to  an  excess  of 
fat  in  an  artificial  food  depends  on  whether  the  condition  is  acute  or 
chronic.  If  the  condition  is  an  acute  one,  it  varies  with  the  se- 
verity of  the  symptoms,  but  is,  in  general,  good.  If  the  condition 
is  a  chronic  one,  the  prognosis  depends  on  the  severity  of  the  symp- 
toms, the  duration  of  the  trouble  and  the  degree  of  the  disturbance 
of  the  nutrition.  It  is  very  grave  in  the  more  marked  cases  and  re- 
covery is  always  slow,  even  in  the  mild  cases.  It  always  takes  a 
long  time  to  reestablish  a  normal  tolerance  for  fat.  Relapses  are 
frequent  and  of  long  duration.  The  least  excess  of  fat  in  the  food  is 
almost  certain  to  bring  one  on. 

The  treatment  of  disturbances  of  the  digestion  caused  by  an  ex- 
cessive amount  of  fat  in  an  artificial  food  consists  in  diminishing 
the  percentage  of  fat  in  the  food.  How  much  the  percentage  of 
fat  is  to  be  cut  down  depends  on  the  severity  and  duration  of  the 
S3niiptoms  in  the  individual  instance. 

It  is  usually  advisable  to  cut  out  the  fat  entirely  in  acute  cases. 
In  them,  however,  it  can  usually  be  cautiously  added  again  in  a 
few  days.  How  rapidly  it  can  be  added  can  only  be  determined  by 
observation  of  the  symptoms  and  examination  of  the  stools. 

It  is  also  advisable  to  cut  out  all  of  the  fat  in  beginning  the 
treatment  of  the  severe,  chronic  cases  of  fat  indigestion.  In  the 
less  serious  cases  it  is  always  wise  to  at  once  reduce  the  percentage 
of  fat  materially.  Time  is  saved,  recovery  is  hastened  and  toler- 
ance established  much  more  quickly,  when  the  percentage  of  fat 
is  immediately  cut  down  below  the  limit  of  tolerance  than  when 
this  point  is  reached  by  several  insufiicient  reductions.  It  is  never 
a  mistake  to  reduce  the  percentage  of  fat  more  than  is  necessary. 
Time  is  always  lost,  if  the  reduction  is  insufficient.  It  is  usually  ad- 
visable to  reduce  the  fat  to  at  least  2%  in  the  mild  cases,  to  1%  in 
the  more  severe  ones,  and  to  cut  it  out  entirely  in  the  most  serious. 
If  the  stools  still  show  an  excessive  amount  of  fat  after  the  initial  re- 
duction has  been  made,  the  percentage  of  fat  must  be  reduced  stiU 
farther.    If  they  do  not  show  any  evidences  of  fat  indigestion,  the 


FAT  INDIGESTION  275 

percentage  of  fat  should  be  cautiously  increased.  Not  more  than 
0.25%  should  be  added  at  a  time.  Several  days  should  intervene 
between  the  changes.  The  stools  should  be  examined  after  each 
change  is  made  to  determine  if  this  amount  of  fat  is  well  borne  be- 
fore the  next  change  is  made.  It  must  never  be  forgotten  that 
when  the  tolerance  for  fat  has  once  been  weakened,  it  is  very 
difficult  to  reestablish  it  and  very  easy  to  break  it  down  again. 

It  must  be  remembered,  on  the  other  hand,  that  the  continuous 
use  of  a  food  low  in  fat  tends  to  weaken  the  power  of  digesting  fat 
and,  therefore,  to  lower  the  tolerance  for  fat.  It  must  also  be  re- 
membered that  the  caloric  value  of  fat  is  very  high  and  that,  if  the 
percentage  of  fat  is  very  low,  the  caloric  value  of  the  food  may  be 
insufficient  to  meet  the  infant's  caloric  requirements.  When  the 
percentage  of  fat  is  much  diminished,  the  percentages  of  the  car- 
bohydrates and  protein  must  be  increased  in  order  to  cover  the  ca- 
loric needs.  This  is  sometimes  very  difficult  to  do  without  setting 
up  a  disturbance  of  the  digestion  through  an  excess  of  one  of  the 
other  food  elements,  since  the  caloric  value  of  fat  is  more  than  twice 
that  of  sugar,  starch  and  protein. 

Babies  with  an  almost  complete  intolerance  for  the  fat  of  cow's 
milk  can  often  take  the  fat  of  human  milk  without  difficulty. 
When,  as  is  sometimes  the  case,  it  is  impossible  to  feed  babies  hav- 
ing an  intolerance  for  fat  satisfactorily  on  artificial  foods  low  in  fat 
on  account  of  the  disturbance  of  the  digestion  caused  by  the  other 
food  elements,  when  the  percentages  of  these  elements  are  made 
high  enough  to  cover  the  caloric  needs,  they  should  be  given  human 
milk.  In  some  cases  imfortunately,  they  are  unable  to  tolerate  the 
fat  of  human  milk.  In  such  instances  skimmed  human  milk  is  the 
only  resource. 

INDIGESTION   FROM  AN  EXCESS  OP  CARBOHYDRATES 

Breast-Milk. — Indigestion  from  an  excess  of  sugar  in  breast- 
milk  is  decidedly  unconmion.  The  percentage  of  sugar  is  very 
seldom  over  seven  and,  if  it  is  1  or  2%  higher,  it  almost  never 
causes  any  disturbance. 

The  main  symptoms  of  an  excessive  amount  of  sugar  in  breast- 
milk  are  flatulence  and  colic,  vomiting  and  abnormal  stools.  The 
disturbance  is  seldom  sufficient  to  cause  any  loss  of  weight.  There 
is  nothing  especially  characteristie  about  the  vomitus.  It  may, 
however,  sometimes  have  the  odor  of  lactic  or  acetic  acid.  The 
stools  are  usually  not  especially  characteristic.  They  are,  however, 
sometimes  loose,  light  green  in  color,  acid  in  reaction  and  irritating 


276  SUGAR  INDIGESTION 

to  the  buttocks.  They  almost  never,  however,  show  the  marked 
evidences  of  carbohydrate  fermentation  so  common  in  the  dis- 
turbances of  digestion  due  to  an  excess  of  milk  sugar  in  artificial 
foods. 

The  disturbance  caused  by  an  excessive  amount  of  sugar  in 
breast-milk  is  never  a  severe  one  and  is  not  usually  of  long  dura- 
tion. 

It  is  possible  that,  if  the  mother  has  been  taking  an  excessively 
large  amount  of  sugar,  a  reduction  in  the  amount  of  sugar  which 
she  takes  may  result  in  a  diminution  in  the  percentage  of  sugar 
in  the  milk.  If  the  amount  of  sugar  ingested  has  been,  however, 
within  reasonable  limits,  cutting  it  down  cannot  be  expected  to  have 
any  effect  on  the  percentage  of  sugar  in  the  milk.  In  most  instances 
it  will  be  found  that  she  has  been  eating  too  much  in  general  rather 
than  too  much  sugar.  Cutting  down  the  food  as  a  whole,  increas- 
ing the  amount  of  exercise  which  she  takes,  and  getting  her  out  of 
doors  more  will  ordinarily  quickly  bring  down  the  percentage  of 
sugar  to  within  normal  limits. 

Artificial  Food. — Indigestion  from  an  excess  of  carbohydrates 
in  an  artificial  food  may  be  due  to  the  excessive  amount  of  either 
starch  or  sugar.  The  sugar  at  fault  may  be  any  one  of  the  sugars 
commonly  used  in  infant  feeding,  milk  sugar,  cane  sugar  or  one  of 
the  dextrin-maltose  combinations.  The  disturbances  of  the  diges- 
tion caused  by  the  various  forms  of  carbohydrates  have  many 
symptoms  in  common.  Each  of  them,  however,  also  produces  cer- 
tain special  symptoms  or  combinations  of  symptoms  which  are 
more  or  less  characteristic. 

Milk  Sugar. — Milk  sugar  in  an  artificial  food  seldom  causes  any 
disturbance  of  the  digestion,  unless  there  is  more  than  7%  of  it 
in  the  mixture.  Six  per  cent,  or  even  5%  will,  however,  sometimes 
cause  trouble  in  susceptible  infants.  It  is  never  safe  to  give  more 
than  7%  continuously.  The  disturbances  caused  by  milk  sugar 
may  be  either  acute  or  chronic,  but  are  more  often  acute.  In  a  con- 
siderable proportion  of  the  cases  of  indigestion  resulting  from  an 
excess  of  milk  sugar,  a  part  of  the  symptoms  are  caused  by  the  prod- 
ucts of  the  fermentation  of  the  sugar  as  the  result  of  bacterial  ac- 
tion. It  is  very  difficult,  and  in  many  instances  impossible,  to  de- 
termine how  much  of  the  symptoms  are  due  to  the  disturbance  of 
the  digestion  of  the  sugar  and  how  much  to  the  products  of  ab- 
normal bacterial  activity  in  the  sugar. 

The  most  prominent  and  characteristic  symptom  of  a  disturb- 
ance of  the  digestion  from  an  excess  of  milk  sugar  is  the  passage  of 
loose,  or  watery,  green,  acid  and  irritating  stools.     They  often 


SUGAR  INDIGESTION  277 

contain  more  or  less  mucus.  The  odor  is  distinctly  acid.  In  some 
instances  the  characteristic  odors  of  lactic,  acetic  and  succinic 
acids  may  be  distinguished.  The  buttocks  and  genitals  are  often 
much  excoriated.  Vomiting  is  a  less  frequent,  but  is  not  an  imcom- 
mon  symptom.  The  vomitus  is  acid  in  reaction,  and  may  also  have 
the  odor  of  lactic,  acetic  or  succinic  acid.  It  is  usually  watery. 
Flatulence  and  colic  are  conmion  symptoms.  Loss  of  weight  is  a 
constant  and  often  a  marked  symptom  in  the  acute  cases;  it  is  usu- 
ally not  very  marked  in  the  chronic  disturbances.  The  temperature 
often  rises  rapidly  and  is  not  infrequently  very  high  in  the  more  sev- 
ere acute  disturbances  of  digestion  resulting  from  an  excess  of  milk 
sugar.  It  is  seldom  of  long  duration.  It  is  doubtful,  however,  if 
the  rise  in  temperature  is  directly  due  to  the  absorption  of  the  su- 
gar. It  is  probable  that  the  explanation  is  not  so  simple.  The 
temperature  is  but  little,  or  not  at  all,  elevated  in  the  more  chronic 
cases.  The  symptoms  of  intoxication  may  be  very  marked  in  the 
more  severe  acute  cases.  Among  them  may  be  mentioned  rest- 
lessness and  other  manifestations  of  disturbance  of  the  nervous 
system,  marked  prostration  and  disturbance  of  the  respiratory 
rhythm. 

The  prognosis  in  the  severe  acute  cases  is  grave.  If  the  patients 
survive  for  forty-eight  hours  after  the  onset  of  the  severe  symp- 
toms, they  usually  recover.  Improvement  is  generally  rapid  after  it 
once  begins.  The  prognosis  in  the  chronic  cases  is  good  as  to  life. 
It  is  usually  some  weeks  or  months,  however,  before  the  tolerance 
for  milk  sugar  is  thoroughly  reestablished.  It  is  usually  much 
easier,  nevertheless,  to  overcome  an  intolerance  for  milk  sugar  than 
one  for  fat. 

In  the  acute  disturbances  of  the  digestion  from  an  excess  of  milk 
sugar,  milk  sugar  must  be  eliminated  as  far  as  possible  from  the 
food.  It  must  be  remembered  in  this  connection  that  whey  con- 
tains between  4.5%  and  5%  of  milk  sugar.  Whey  and  whey  mix- 
tures are,  therefore,  contraindicated  in  this  condition.  Fat  is  also 
usually  not  well  tolerated.  Small  percentages  of  starch  are  ordi- 
narily well  borne.  This  is  because  the  starch  is  broken  down  slowly 
and  because  its  end-product,  dextrose,  is  quickly  absorbed.  There 
is,  therefore,  never  much  sugar  in  the  intestine  at  one  time.  The 
indications  are,  therefore,  for  mixtures  containing  but  little  fat  and 
milk  sugar  and  a  considerable  amount  of  protein,  with  or  without 
the  addition  of  starch.  Mixtures  containing  from  0.50%  to  1%  of 
fat,  1%  to  1.50%  of  milk  sugar  and  1%  to  2%  or  even  2.50%  of 
protein,  with  from  0.50%  to  0.75%  of  starch  are  suitable  ones. 
Mixtures  of  skimmed  milk  with  a  cereal  diluent,  in  various  propor- 


278  SUGAR  INDIGESTION 

tions,  also  meet  these  indications.  It  is  usually  somewhat  difficult 
to  cover  the  caloric  needs  of  the  infants  with  mixtures  of  this 
general  character.  It  is  therefore  advisable,  after  a  few  days,  to 
add  one  of  the  dextrin-maltose  combinations  to  the  mixture,  in 
order  to  bring  up  its  caloric  value.  It  is  usually  possible  to  return 
after  a  short  time  to  milk  sugar.  Eiweissmilch  sometimes  works 
very  well  in  these  cases.  So  also  do  mixtures  prepared  with  pre- 
cipitated casein,  because  in  this  way  high  percentages  of  protein 
can  be  given  in  combination  with  very  low  percentages  of  milk 
sugar. 

Human  milk  is  contraindicated  in  these  cases,  because  of  the 
high  percentage  of  milk  sugar  which  it  contains.  It  is  usually  well 
borne,  however,  after  the  acute  sjonptoms  have  subsided  and  in 
convalescence  is,  as  always,  the  best  food. 

In  the  more  chronic  disturbances  of  digestion  due  to  an  excess  of 
milk  sugar,  it  is  advisable  to  at  once  cut  out  all  the  milk  sugar  which 
is  being  added  to  the  food,  thus  reducing  the  percentage  of  milk 
sugar  to  that  which  is  necessarily  put  into  the  food  in  the  cream  and 
milk.  If  the  mixture  is  in  other  respects  a  suitable  one,  the  per- 
centages of  the  fat  and  protein  may  be  left  unchanged.  It  is  often 
advisable,  however,  to  increase  the  percentage  of  protein  a  little, 
in  order  to  bring  up  the  caloric  value  of  the  food.  The  percentage 
of  fat  may  also  be  increased  for  the  same  reason,  but  this  must  be 
done  cautiously,  because  there  is  very  likely  to  be  a  diminution  in 
the  tolerance  for  fat  when  there  is  a  disturbance  in  the  digestion  of 
milk  sugar.  If  the  caloric  value  of  the  food  is  still  too  low,  it  may 
be  increased  after  a  few  days  by  the  addition  of  one  of  the  dextrin- 
maltose  combinations.  Starch  may  also  be  added  to  the  amount  of 
0.50%  or  0.75%. 

In  mild  cases  it  is  often  possible  to  gradually  put  back  enough  of 
the  milk  sugar,  increasing  it  0.50%,  or  even  1.00%,  at  a  time,  to 
cover  the  caloric  needs  without  causing  a  recurrence  of  the  symp- 
toms. In  such  instances  it  is  not  necessary  to  fall  back  on  the 
dextrin-maltose  preparations  or  starch.  It  is  advisable  to  replace 
the  dextrin-maltose  preparations  by  milk  sugar  as  soon  as  this  is 
possible. 

Whey  and  whey  mixtures  are  contraindicated  in  these  cases, 
because  of  the  high  percentage  of  milk  sugar  in  whey.  Eiweiss-  ' 
milch  or  mixtures  prepared  with  precipitated  casein  are  often 
useful  in  these  cases,  because  a  high  percentage  of  protein  may  be 
given  in  this  way  in  combination  with  a  very  low  percentage  of 
milk  sugar.  One  of  the  dextrin-maltose  preparations  or  starch  may 
be  added  to  these  mixtures,  if  desired. 


SUGAR  INDIGESTION  279 

Cane  Sugar. — The  sjmaptoms  of  disturbance  of  the  digestion, 
whether  acute  or  chronic,  from  an  excess  of  cane  sugar  in  the  food 
are  essentially  the  same  as  those  from  an  excess  of  milk  sugar. 
Extreme  elevations  of  the  temperature  in  acute  disturbances  are, 
however,  somewhat  less  common.  Babies  that  get  a  large  amount 
of  cane  sugar  in  their  food  not  infrequently  show  evidences  of  dis- 
turbance of  the  nutrition  for  some  time  before  the  appearance  of 
the  symptoms  of  disturbance  of  the  digestion.  They  become  fat, 
flabby  and  pale  and  their  resistance  to  infection  and  disease  is 
materially  diminished. 

The  prognosis  in  disturbances  of  the  digestion  due  to  an  excessive 
amount  of  cane  sugar  is  essentially  the  same  as  that  in  the  dis- 
turbances due  to  milk  sugar.  It  is  not  quite  as  good  in  the  chronic 
cases,  however,  because  of  the  greater  disturbance  of  the  nutrition 
produced  by  the  long-continued  use  of  large  amounts  of  cane 
sugar. 

The  treatment  of  disturbances  of  the  digestion  due  to  an  exces- 
sive amoimt  of  cane  sugar  is  along  the  same  hues  as  when  the 
disturbance  is  caused  by  milk  sugar.  The  cane  sugar  should  be  at 
once  cut  out  entirely,  the  percentage  of  sugar  in  the  food  thus  being 
reduced  to  that  of  the  milk  sugar  which  is  contained  in  the  cream 
and  milk  in  the  mixture.  After  the  symptoms  of  disturbance  have 
ceased  the  percentage  of  sugar  can  then  be  gradually  increased  by 
the  addition  of  milk  sugar.  If  the  sjnnptoms  recur  when  milk 
sugar  is  added  to  the  mixture,  one  of  the  dextrin-maltose  prepara- 
tions can  be  substituted  for  it.  Starch  may  also  be  added  in  order 
to  increase  the  caloric  value  of  the  food. 

Dextrin-Maltose  Preparations. — The  symptoms  of  disturb- 
ance of  the  digestion  from  an  excess  of  one  of  the  dextrin-maltose 
preparations  are  similar  to  those  caused  by  the  other  sugars.  The 
odor  of  the  vomitus  is  acid,  as  in  the  case  of  the  other  sugars,  but 
this  odor  is  somewhat  different,  probably  because  of  the  presence 
in  many  instances  of  butyric  acid.  Flatulence  and  cohc  are  usually 
more  marked  than  when  the  disturbance  is  caused  by  the  other 
sugars.  The  stools  are  usually  loose  or  watery,  and  dark-brown  in 
color,  but  are  sometimes  green.  The  odor  is  usually  a  peculiarly 
acrid  one.  Sometimes,  however,  it  is  that  of  butyric  acid.  The 
stools  are  strongly  acid  in  reaction  and  cause  very  marked  irritation 
of  the  buttocks,  thighs  and  genitals.  The  elevation  of  the  tempera- 
ture in  acute  cases  due  to  an  excess  of  the  dextrin-maltose  prepara- 
tions is  usually  less  than  when  they  are  due  to  the  other  sugars. 

The  prognosis  in  the  disturbances  of  the  digestion  caused  by  the 
dextrin-maltose  preparations  is  somewhat  better  than  in  those 


280.  STARCH  INDIGESTION 

brought  on  by  the  other  sugars.  The  acute  disturbances  are 
usually  rather  less  severe  and  both  the  acute  and  chronic  disturb- 
ances are  somewhat  more  amenable  to  treatment. 

The  treatment  of  the  disturbances  of  the  digestion  caused  by  an 
excess  of  the  dextrin-maltose  preparations  is  along  the  same  lines  as 
when  the  trouble  is  due  to  the  other  sugars.  It  consists  primarily 
in  the  immediate  withdrawal  of  the  preparation.  After  one  or 
two  days  the  preparation  may  be  cautiously  added  again  or,  as  is 
usually  better,  milk  sugar  substituted  for  it.  When  an  intolerance 
for  sugar  in  general  has  been  established,  the  caloric  value  of  the 
food  may  be  raised  by  increasing  the  percentage  of  protein  in  the 
food  and  adding  starch.  It  must  be  remembered  in  this  connection 
that  the  larger  the  proportion  of  maltose  in  these  dextrin-maltose 
preparations,  the  greater,  in  general,  is  their  laxative  action. 
Sometimes,  therefore,  in  the  mild  chronic  disturbances  of  digestion, 
the  substitution  of  another  preparation  containing  a  larger  propor- 
tion of  the  dextrins  will  relieve  the  symptoms. 

Starch. — The  disturbances  of  digestion  caused  by  foods  com- 
posed entirely  of  starch  are  more  often  chronic  than  acute.  Vomit- 
ing is  a  relatively  uncommon  symptom.  Flatulence  and  colic  are 
more  common.  The  bowels  are  sometimes  constipated;  sometimes 
there  is  diarrhea.  When  the  bowels  are  constipated  the  stools  are 
small  and  brown.  In  some  instances  they  are  dry  and  crumbly. 
Constipation  in  these  instances  is  the  result  of  the  insufficient 
amount  of  food,  so  much  of  the  food  being  absorbed  that  there  is 
but  little  left  over  to  form  feces.  These  stools  have  but  Uttle  odor. 
Their  reaction  varies  from  acid  to  alkaline,  according  to  whether 
the  bulk  of  the  stool  is  formed  from  starch  remains  or  from  the 
intestinal  secretions. 

When  the  stools  are  loose  the  color  is  brown  and  they  have  the 
appearance  of  mucus.  In  fact,  they  are  often  thought  to  contain 
mucus  or  to  be  composed  entirely  of  mucus.  The  addition  of  some 
preparation  of  iodine  to  them  will,  however,  turn  them  dark  blue, 
showing  that  they  are  composed  of  unchanged  starch  and  not  of 
mucus.  If  the  condition  is  not  severe  enough  to  give  the  starch 
test  macroscopically,  it  will  be  plainly  visible  microscopically. 
These  stools  are  acid  in  reaction.  Their  odor  is  acid,  but  only 
slightly  so. 

The  disturbance  of  the  nutrition  caused  by  foods  composed 
entirely  of  starch  is  far  more  serious  than  the  disturbances  of  the 
digestion.  This  disturbance  of  the  nutrition  is  due  in  part  to  the 
insufficient  caloric  value  of  these  foods,  but  far  more  to  their  de- 
fiiciency  in  protein  and  salts.    Babies  fed  exclusively  on  starchy 


STARCH  INDIGESTION  .      281 

foods  may  seem  to  thrive  for  a  time  in  that  they  gain  in  weight,  are 
of  a  fair  color,  and  seem  hvely  and  well.  Careful  examination,  even 
at  this  time,  will  show,  however,  that  there  is  an  exaggerated  mus- 
cular tonicity.  This  is  an  early  manifestation  of  the  disturbance 
of  nutrition.  In  a  few  weeks,  however,  they  begin  to  lose  in  weight 
and  color  and  their  muscles  become  flabby.  If  the  exclusively 
starchy  diet  is  continued,  they  gradually  take  on  all  the  character- 
istics of  the  starved,  atrophic  infant.  Many  of  them  die  of  inter- 
current infections,  however,  before  reaching  this  stage,  the  resist- 
ance to  infection  being  especially  lowered  in  the  disturbances  of 
nutrition  caused  by  a  diet  consisting  entirely  of  starch. 

The  prognosis  in  these  cases  of  chronic  disturbance  of  the  diges- 
tion due  to  an  exclusively  starchy  diet  is  always  a  grave  one,  partly 
because  of  the  marked  disturbance  of  the  nutrition  and  partly  be- 
cause of  the  marked  lowering  of  the  resistance  to  infection  induced 
by  it.  It  is  always  many  weeks,  and  often  months,  before  the  dis- 
turbance of  the  nutrition  is  entirely  overcome.  The  prognosis  in 
the  acute  cases  is  very  good.  They  are  usually  very  amenable  to 
proper  treatment. 

The  treatment  in  the  acute  cases  is  the  immediate  and  complete 
withdrawal  of  the  starchy  food.  A  modified  milk,  in  which  the  per- 
centages are  all  low  and  in  which  the  relation  of  the  fat,  milk  sugar 
and  protein  to  each  other  are  similar  to  those  in  human  milk,  can 
usually  be  given  at  once.    Examples  of  such  mixtures  are: 

Fat 1.00% 

Milk  Sugar 4.00% 

Protein 0.75%  and 

Fat 2.00% 

Milk  Sugar 5.00% 

Protein 1.25% 

Whey  and  whey  mixtures  are  often  useful  under  these  conditions. 

The  treatment  in  the  chronic  cases  is  along  the  same  Hues.  It  is 
more  difficult  to  fit  the  food  to  the  digestive  capacity  in  these  cases, 
however,  because  the  functions  of  the  digestion  and  metabolism  of 
fat  and  protein  have  usually  been  materially  weakened  by  disuse 
and  by  the  impairment  of  the  nutrition.  It  is  always  advisable  in 
these  cases,  therefore,  to  give  human  milk,  if  it  can  possibly  be  ob- 
tained. 

The  disturbance  of  the  nutrition  when  the  purely  starchy  foods 
are  partially  dextrinized  is  as  great  as  when  they  are  not.  The 
symptoms  of  disturbance  of  the  digestion  from  starch  are,  however, 


282  STARCH  INDIGESTION 

diminished,  although  those  from  an  excess  of  malt  sugar  may  take 
their  place.  When  the  dextrin-maltose  preparations  or  other 
sugars  are  added  to  the  starchy  foods  their  caloric  value  is  in- 
creased and  to  this  extent  the  disturbance  of  the  nutrition  is  di- 
minished. That  due  to  the  deficiency  of  protein  and  salts  is,  how- 
ever, unaffected.  The  symptoms  of  disturbance  of  the  digestion 
caused  by  these  sugary  and  starchy  foods  are  a  combination  of 
those  due  to  an  excess  of  starch  and  of  those  due  to  an  excess  of 
sugar.  The  sjmaptoms  caused  by  the  excess  of  sugar  usually  pre- 
dominate. 

When  starch  is  added  in  excess  to  a  food  of  which  milk  forms  the 
basis  it  causes  but  little  disturbance  of  the  nutrition  and  relatively 
little  disturbance  of  the  digestion.  It  seldom  causes  vomiting,  but 
not  infrequently  causes  flatulence  and  colic.  It  sometimes  makes 
the  stools  harder  and  drier.  It  more  often  causes  a  looseness  of  the 
bowels.  The  stools  are  more  acid  than  normal,  have  an  acid  odor 
and  irritate  the  buttocks.  The  undigested  starch  may  be  visible 
in  the  movements  and  may  be  mistaken  for  mucus.  If  it  is  visible, 
it  will  turn  dark  blue  when  a  preparation  of  iodine  is  added  to  the 
stool.  If  it  is  not  visible  macroscopically,  it  can  be  found  in  all 
cases  microscopically.  It  is  almost  invariably  associated  with  the 
presence  of  numerous  iodophilic  bacteria.  These  organisms  are 
often  found,  moreoever,  before  starch  itself  can  be  detected  and, 
when  found,  they  always  suggest  that  a  disturbance  of  the  diges- 
tion from  starch  is  imminent. 

Disturbance  of  the  digestion  from  starch  is  much  less  likely  to 
occur,  if  the  starch  is  thoroughly  cooked.  It  almost  never  de- 
velops unless  there  is  1%  or  more  of  starch  in  the  mixture. 

The  prognosis  of  the  disturbances  of  digestion  caused  by  an  ex- 
cess of  starch  in  mixtures  the  basis  of  which  is  milk  is  good.  Re- 
covery is  ordinarily  prompt  when  the  cause  is  removed. 

The  treatment  consists  in  cutting  the  starch  entirely  out  of  the 
food  for  a  time.  It  can  ordinarily  be  put  back  in  reasonable  amounts 
after  a  short  time.  The  trouble  will  seldom  recur,  if  the  percentage 
of  starch  is  not  over  0.75%. 

INDIGESTION   FROM   AN   EXCESS  OF   PROTEIN 

Breast-Milk. — Indigestion  from  an  excess  of  protein  in  human 
milk  is  much  more  common  than  from  an  excess  of  either  fat  or 
milk  sugar.  The  protein  is  more  likely  to  be  excessive  during  the 
early  part  of  lactation,  before  the  equilibrium  of  the  milk  has  been 
established  and  the  mother  has  resumed  her  normal  life,  than  later. 
The  excess  of  protein  may  be  due  to  anxiety  or  nervousness  on  the 


PROTEIN  INDIGESTION  283 

part  of  the  mother,  or  to  either  fatigue  or  lack  of  exercise,  all  of 
which  increase  the  protein  content  of  the  milk.  It  is  impossible  to 
know  in  advance  what  percentage  of  protein  will  be  an  excess  for 
the  individual  infant.  Some  babies  are  disturbed  if  the  protein  is 
more  than  1.50%,  while  others  can  take  2.50%  or  even  3.00% 
without  being  disturbed  in  any  way. 

Vomiting,  while  it  does  occur,  is  a  comparatively  uncommon 
symptom  of  indigestion  from  an  excess  of  protein  in  breast-milk. 
Flatulence  and  colic,  on  the  other  hand,  are  very  common  symp- 
toms and  are  often  very  marked  and  very  troublesome.  There  is 
almost  invariably  an  increase  in  the  number  of  the  stools,  which  are 
either  loose  or  watery.  They  are  usually  brownish-yellow  instead 
of  golden  in  color,  but  may  be  green.  They  not  infrequently  con- 
tain mucus  and  often  fine,  soft,  fat  curds.  These  may  be  due  to  a 
coincident  fat  indigestion,  but  are  more  often  due  to  the  increased 
peristalsis  and  consequent  interference  with  absorption.  The 
reaction  is  alkaline  or  feebly  acid.  The  odor  is  not  characteristic. 
It  may  be  acid  or  a  little  foul.  The  stools  do  not  ordinarily  irritate 
the  buttocks.  The  temperature  may  be  slightly  elevated,  but 
ordinarily  is  not.  In  some  instances,  however,  when  the  disturb- 
ance is  an  acute  one  from  a  sudden  and  marked  increase  in  the  per- 
centage of  protein,  the  temperature  may  be  considerably  elevated. 
The  nutrition  is  not  as  much  affected  as  would  be  expected  from  the 
amount  of  digestive  disturbance.  There  is  ordinarily  not  much 
loss  of  weight.  Many  babies  continue  to  gain,  although  slowly, 
while  occasionally  a  baby  will  gain  rapidly  in  spite  of  much  colic 
and  many  loose  stools. 

Disturbance  of  the  digestion  from  an  excess  of  protein  in  breast- 
milk  is  usually  rapidly  recovered  from,  if  the  cause  of  the  excess  can 
be  removed.  The  results  are  seldom  lasting.  In  rare  instances, 
however,  when  there  is  a  sudden  and  very  marked  increase  in  the 
percentage  of  protein,  the  babies  may  die  within  a  few  days.  It  is 
possible,  however,  that  the  cause  of  death  in  such  cases  may  not 
be  the  excessive  amount  of  protein  but  some  unrecognizable  chem- 
ical change  in  the  milk. 

The  treatment  of  indigestion  from  an  excess  of  protein  in  breast- 
milk  consists  primarily  in  regulation  of  the  mother's  diet  and  life 
in  order  to  reduce  the  percentage  of  protein  in  the  milk.  When  the 
percentage  of  protein  is  excessive,  while  the  percentages  of  fat  and 
sugar  are  within  normal  limits,  but  little  can  be  done  to  diminish 
the  percentage  of  protein  alone.  Diminishing  the  relative  propor- 
tion of  protein  in  the  diet  should,  however,  be  tried.  When  the 
percentages  of  fat  and  sugar,  as  well  as  that  of  the  protein,  are  high, 


284  PROTEIN  INDIGESTION 

it  is  possible  to  reduce  them  all  simultaneously  to  a  certain  extent 
by  cutting  down  the  amount  of  food  and  increasing  the  amount  of 
exercise  which  the  mother  takes.  Increasing  the  length  of  the  in- 
tervals between  the  nursings  will  also  diminish  the  percentage  of 
protein  together  with  those  of  the  other  elements.  The  percentage 
of  protein  may  also  be  diminished  by  giving  the  baby  water  at  the 
time  of  the  nursing.  The  percentages  of  fat  and  sugar  are,  how- 
ever, also  diminished  to  the  same  extent. 

When  the  high  percentage  of  protein  is  the  result  of  inactivity  on 
the  part  of  the  mother,  it  can  be  diminished  by  making  her  take 
more  exercise.  Exercise  in  the  open  air  is  preferable  to  that  in- 
doors. Care  must  be  taken,  however,  that  she  does  not  take  too 
much  exercise  and  become  fatigued,  because  fatigue  increases  the 
protein.  If  the  excess  of  protein  in  the  milk  is  due  to  fatigue  or 
overwork,  it  can  be  diminished  by  resting  the  mother  and  keeping 
her  more  quiet. 

When  the  high  percentage  of  protein  is  due  to  nervousness, 
worry  or  anxiety,  the  remedy  is  obvious.  The  removal  of  the 
cause  will  at  once  result  in  a  diminution  in  the  percentage  of 
protein.  It  is,  however,  unfortunately,  seldom  possible  to  modify  a 
woman's  natural  temperament  and  frequently  very  difficult  to 
remove  causes  of  anxiety  and  worry. 

Artificial  Food. — A  disturbance  of  the  digestion  is  almost  never 
due  to  an  excess  of  protein  in  an  artificial  food,  unless  that  food  is 
cow's  milk  or  some  modification  of  cow's  milk.  When  there  is  a 
disturbance  of  the  digestion  as  the  result  of  an  excess  of  the  protein 
in  cow's  milk,  the  excess  is  ahnost  invariably  of  casein,  not  of  whey 
protein. 

Whey  Protein. — When  babies  that  are  being  fed  on  whey  or  on 
mixtures  containing  a  high  percentage  of  whey  protein  have  a  dis- 
turbance of  the  digestion,  this  disturbance  is  in  the  vast  majority 
of  instances  due  to  the  milk  sugar  and  salts  in  the  whey  rather  than 
to  the  whey  protein  itself.  The  symptoms  are,  therefore,  those  of 
an  excess  of  milk  sugar  and  of  salts.  It  is  probable,  however,  that 
in  rare  instances  the  whey  proteins  may  cause  a  disturbance  of  the 
digestion.  The  chief  symptom  of  such  a  disturbance  of  the  diges- 
tion is  the  presence  of  an  increased  number  of  loose,  watery  stools. 
There  may  also  be  flatulence  and  colic.  The  stools  may  be  normal 
in  character,  except  for  their  diminished  consistency,  but  are  some- 
times brownish  and  alkaline,  with  a  musty  odor. 

The  disturbance  of  the  digestion  from  an  excess  of  whey 
protein  is  usually  not  a  severe  one  and  ordinarily  yields  promptly 
to  proper  treatment. 


PROTEIN  INDIGESTION  285 

The  treatment  of  a  disturbance  of  the  digestion  from  an  excess  of 
whey  protein  consists  in  stopping  the  whey  or  diminishing  the  per- 
centage of  whey  protein,  and  giving  the  necessary  percentage  of 
protein  in  the  form  of  casein. 

Casein. — The  symptoms  of  disturbance  of  the  digestion  from  an 
excess  of  casein  are  vomiting,  flatulence  and  coHc,  abnormal  stools, 
somnolence  and  disturbance  of  the  nutrition.  The  vomitus  often 
contains  very  large  curds.  These  curds  may  be  fairly  soft  or  tough 
and  leathery.  The  vomitus  ordinarily  has  but  little  odor.  It  may 
smell  shghtly  acid,  but  is  never  strongly  acid.  Flatulence  and  colic 
are  often  quite  severe.  The  chief  abnormality  in  the  stools  is  the 
presence  of  large,  hard  curds.  The  number  of  stools  may  or  may 
not  be  increased.  In  many  instances  the  stools  are  normal  in  char- 
acter, except  for  the  presence  of  the  curds.  In  other  instances,  how- 
ever, there  may  be  an  increased  number  of  loose  or  watery  stools, 
brownish  in  color  and  alkaline  in  reaction.  The  odor  is  musty. 
These  stools  at  times  contain  an  excess  of  mucus,  but  almost  never 
curds.  The  disturbance  of  the  nutrition  from  an  excess  of  casein  in 
the  food  is  usually  not  very  marked.  There  is  ordinarily  no  fever, 
but  in  some  instances  the  temperature  is  moderately  elevated. 
If  the  temperature  is  high,  it  is  probably  due  to  some  other 
cause,  such  as  an  excess  of  salts. 

The  prognosis  of  disturbances  of  the  digestion  caused  by  an  ex- 
cess of  casein  is  usually  good.  It  is  not  a  difficult  matter,  in  most 
instances,  to  correct  the  disturbance  by  diminishing  the  percentage 
of  casein  or  by  the  use  of  one  of  the  numerous  methods  for  prevent- 
ing the  formation  of  large  casein  curds. 

When  the  disturbance  of  the  digestion  of  protein  results  in  the 
passage  of  watery,  brown,  musty  stools,  the  protein  must  be  cut 
entirely  out  of  the  diet  for  a  time  and  some  form  of  carbohydrate 
be  given  in  its  place.  Any  of  the  cereal  waters,  to  which  milk  sugar 
or  one  of  the  dextrin-maltose  preparations  may  be  added,  is  suit- 
able. Protein,  best  in  the  form  of  casein,  must  be  added  again  as 
soon  as  possible,  however,  in  order  to  prevent  serious  disturbance 
of  the  nutrition  from  the  loss  of  body  protein  as  the  result  of  the 
lack  of  protein  in  the  food. 

When  the  disturbance  of  digestion  shows  itself  by  the  vomiting 
of  large  curds,  flatulence  and  colic,  and  the  passage  of  large,  hard 
curds  in  the  stools,  the  object  of  the  treatment  is  to  prevent  the 
formation  of  large  curds  in  the  stomach.  If  they  are  not  formed 
there,  they  will  not  be  formed  lower  down.  If  the  formation  of 
large  curds  can  be  prevented,  the  casein  will,  in  most  instances 
cause  no  disturbance.    The  simplest  way  to  prevent  the  formation 


286  PROTEIN  INDIGESTION 

of  large  casein  curds  is  to  diminish  the  percentage  of  casein  in  the 
milk  mixture.  When  this  plan  is  adopted,  great  care  must  be  taken 
not  to  diminish  the  percentage  of  protein  so  much  that  the  protein 
need  of  the  baby  is  not  covered. 

A  portion  of  the  protem  may  be  given  in  the  form  of  whey  pro- 
tein. In  this  way  the  formation  of  large  curds  is  prevented  and 
yet  the  protein  need  of  the  baby  can  be  covered.  There  are  many 
methods  for  preventing  the  formation  of  large  casein  curds.  These 
methods  are  very  different,  but  the  result  obtained  with  all  of  them 
is  the  same.  In  some  way  or  other  the  production  of  large  casein 
curds  is  prevented  or  at  least  hindered.  Some  of  these  methods  are 
boiling  the  milk,  the  addition  of  cereal  diluents,  the  addition  of 
lime  water  or  other  alkalis  to  the  mixture,  the  addition  of  citrate  of 
soda,  and  "peptonization"  of  the  milk.  Another  way  of  prevent- 
ing the  formation  of  large  casein  curds  is  by  using  buttermilk.  Still 
another  way  is  by  the  use  of  precipitated  casein  in  the  milk  mix- 
tures, or  in  the  form  of  Eiweissmilch.  It  is  often  very  hard  to  de- 
cide which  method  to  use  in  a  given  case.  A  careful  study  of  the 
conditions  in  the  case  and  a  thorough  comprehension  of  the  way  in 
which  the  formation  of  casein  curds  is  prevented  in  each  method 
will  usually  show,  however,  which  one  is  the  most  suitable  one  un- 
der the  circumstances.  These  methods  are  fully  described  on  pages 
202  to  205. 

INDIGESTION   FROM  AN  EXCESS   OF   SALTS 

There  is  no  doubt  that  the  salts  play  a  most  important  part  in 
the  metabolism  of  the  other  food  elements  and  that  the  metabolic 
processes  cannot  progress  normally  unless  the  proper  salts  are  pres- 
ent in  the  proper  proportions.  There  is  unquestionably  a  dis- 
turbance of  the  metabolism  of  the  salts  in  all  disturbances  of  nu- 
trition in  infancy.  It  is  very  difficult  to  determine,  however, 
whether  the  disturbance  of  the  nutrition  in  any  given  case  is  due 
primarily  to  a  disturbance  of  the  salt  metabolism  from  an  in- 
suflBciency  or  improper  combination  of  the  salts  in  the  food  or 
whether  the  disturbance  of  the  salt  metabolism  is  secondary  to  an 
insufficiency,  excess,  or  improper  combination  of  one  or  more  of 
the  other  food  elements  and  to  the  disturbance  of  the  digestion 
caused  by  them. 

There  is  no  doubt,  moreover,  that  the  salts  play  an  important 
part  in  every  digestive  disturbance  in  infancy.  It  is  probable,  but 
not  certain,  that  the  salts  may  of  themselves  cause  disturbance  of 
the  digestion  independently  of  the  other  food  elements.  Very 
little  is  known  as  to  the  symptoms  which  an  insufficiency  or  an  ex- 


INDIGESTION  FROM  SALTS  287 

cess  of  the  salts  as  a  whole  in  the  food  may  cause.  If  the  salts  are 
cut  out  of  a  food,  which  is  otherwise  unchanged,  the  weight  falls. 
When  they  are  put  back  again,  the  weight  rises.  This  variation  in 
the  weight  is  probably  largely,  but  not  entirely,  due  to  variations 
in  the  retention  of  water.  The  sodium  salts  favor  the  retention  of 
water.  The  salts  of  calcium  diminish  its  retention  to  a  moderate 
extent.  It  is  also  known  that  the  withdrawal  of  salts  from  the  food 
results  in  a  lowering  of  the  body  temperature.  An  excess  of  cal- 
cium in  the  food  also  lowers  the  temperature.  If  a  large  amount  of 
sodium  chloride  is  given  to  a  baby  suffering  from  a  disturbance  of 
.the  digestion,  there  is  usually  a  rise  in  the  temperature.  If  there  is 
no  disturbance  of  the  digestion,  there  is  ordinarily  no  elevation  of 
the  temperature.  Variations  in  the  weight  and  temperature  are, 
however,  common  to  all  disturbances  of  the  digestion  and  do  not, 
therefore,  justify  the  diagnosis  of  indigestion  as  the  result  of  some 
abnormality  in  the  salts  of  the  food.  There  being  no  symptoms 
pecuUar  to  abnormalities  in  the  salts  of  the  foods,  it  is,  therefore, 
impossible  at  present  to  make  a  diagnosis  of  indigestion  from  an 
excess  or  from  an  improper  combination  of  the  salts  in  the  food. 
The  condition  may  be  suspected,  but  that  is  all. 

It  being  impossible  to  make  a  positive  diagnosis  of  indigestion 
from  an  excess  or  an  improper  combination  of  the  salts  in  the  food, 
it  is  evidently  impossible  to  make  a  definite  prognosis  or  to  lay 
down  any  rules  for  treatment. 

The  Medicinal  Treatment  of  Disturbances  of  the  Digestion 
in  Infancy. — The  treatment  of  the  disturbances  of  digestion  in  in- 
fancy consists  primarily  in  regulation  of  the  diet.  All  other 
methods  of  treatment  are  relatively  unimportant.  They  have  their 
place,  however,  and  cannot  be  dispensed  with.  They  are  especially 
useful  for  the  relief  of  symptoms. 

In  the  first  place,  the  bowels  should  be  throughly  cleaned  out 
in  every  acute  disturbance  of  the  digestion,  whatever  its  cause, 
unless  this  disturbance  is  very  slight.  The  most  useful  drug  for 
this  purpose  is  castor  oil,  because  it  is  effective,  acts  quickly  and 
causes  less  irritation  of  the  bowels  than  calomel  and  strong  saUnes.* 
The  dose  should  be  from  one  to  three  teaspoonfuls,  according  to 
the  age  of  the  baby  and  the  effect  desired.  Babies  do  not,  as  a 
rule,  object  to  the  taste  of  castor  oil.  In  fact,  most  babies  like  it. 
No  attempt  should  be  made,  therefore,  to  disguise  its  taste.  The 
stools  produced  by  castor  oil  always  contain  mucus.  Too  much 
importance  must  not  be  attached,  therefore,  to  the  presence  of 
mucus  in  the  stools  after  a  dose  of  castor  oil. 

^  Abt.  Archives  of  Pediatrics,  1909,  xxvi,  836. 


288  MEDICINAL  TREATMENT 

If  less  vigorous  catharsis  is  desired  than  that  usually  produced 
by  castor  oil,  milk  of  magnesia  may  be  used  in  its  place.  The 
dose  is  from  one  to  three  teaspoonfuls,  according  to  the  age  of 
the  baby  and  the  effect  desired.  It  may  be  given  in  the  food,  plain, 
or  diluted  with  water. 

Castor  oil  should  be  tried  first,  even  if  the  baby  is  vomiting. 
It  will  often  be  retained  when  food  is  vomited.  If  it  is  vomited, 
calomel  may  then  be  tried.  It  is  best  given  in  doses  of  one-tenth 
of  a  grain  combined  with  one  grain  of  bicarbonate  of  soda,  every 
half-hour,  until  one  grain  has  been  taken.  It  is  advisable,  but  not 
necessary,  to  give  one  or  two  teaspoonfuls  of  the  milk  of  magnesia 
three  or  four  hours  after  the  last  dose  of  calomel.  It  should  not  be 
forgotten  that  calomel  often  gives  the  stools  a  peculiar  green  color 
that  may  be  mistaken  for  that  resulting  from  disturbances  of  the 
digestion  in  which  the  stools  are  excessively  acid. 

If  the  disturbance  of  the  digestion  is  acute,  severe  and  associated 
with  considerable  elevation  of  the  temperature,  it  is  also  advisable 
to  wash  out  the  colon  with  salt  solution  or  at  least  to  give  an  enema 
of  suds  to  clean  out  the  bowel  from  below. 

When  the  disturbance  of  the  digestion  is  a  chronic  one,  it  is,  as  a 
rule,  inadvisable  to  begin  treatment  with  an  initial  catharsis. 
Catharsis  is  a  weakening  procedure  and,  when  a  baby  is  in  a  debili- 
tated and  feeble  condition  as  the  result  of  a  long  disturbance  of 
the  nutrition,  is  liable  to  do  serious  injury.  When  the  disturbance 
of  nutrition  is  extreme  it  may,  in  fact,  take  away  the  baby's  last 
chance  of  recovery. 

When  babies  with  acute  disturbances  of  digestion  are  vomiting, 
all  food  should  be  stopped.  They  may  be  given  water  to  which 
bicarbonate  of  soda,  in  the  proportion  of  one  level  teaspoonful  to 
eight  ounces  of  water,  has  been  added,  in  teaspoonful  doses,  every 
ten  to  thirty  minutes.  If  the  vomiting  is  severe  or  persistent,  the 
stomach  should  be  washed  out  once  or  twice  daily  with  a  solution 
of  bicarbonate  of  soda  of  the  strength  of  one  rounded  teaspoonful 
to  a  pint  of  water. 

It  is  not  a  difficult  matter  to  wash  out  the  stomach  of  a  baby. 
There  is  usually  no  difficulty  in  introducing  the  catheter,  even  in 
the  youngest  baby.  A  soft  rubber  catheter,  No.  16,  American 
scale,  or  one  a  little  smaller  is  used.  The  catheter  should  be  at- 
tached by  a  short  piece  of  glass  tubing  to  a  rubber  tube  attached 
to  a  funnel.  The  baby  should  be  well  wrapped  up  and  it  and  the 
nurse  protected  by  a  rubber  apron  or  sheet.  The  baby  should  be 
held  upright  in  the  nurse's  lap,  facing  forward  and  bending  a  little 
forward.    The  mouth  can  be  held  open  by  the  forefinger  of  the 


MEDICINAL  TREATMENT  289 

left  hand,  around  which  a  towel  may  be  wrapped.  The  catheter, 
which  is  held  in  the  right  hand,  is  then  pushed  to  the  back  of  the 
throat  and  downward.  It  passes  most  easily  when  the  baby  gags. 
The  distance  from  the  gums  or  incisor  teeth  to  the  cardia  during 
infancy  is  between  seven  and  eight  inches.  The  catheter  should, 
therefore,  not  be  introduced  farther  than  this.  It  is  very  difficult 
to  pass  the  catheter  anywhere  except  into  the  esophagus.  It  is 
possible,  however,  to  pass  it  through  the  larynx.  Water  should 
never  be  poured  in,  therefore,  until  the  baby  has  cried  clearly  or 
food  has  come  up  through  the  tube.  It  is  easier  to  start  the  si- 
phonage  if  the  tube  is  introduced  full  of  water.  The  washing  should 
be  continued  until  the  water  returns  clear. 

It  is  rarely  necessary  or  advisable  to  give  an  emetic  to  in- 
fants suffering  from  disturbances  of  the  digestion.  A  teaspoon- 
ful  of  the  wine  of  ipecac  is  the  safest  and  best,  if  an  emetic  is 
necessary. 

The  best  treatment  for  the  flatulence  and  coUc  associated  with 
disturbances  of  digestion  is  the  removal  of  the  cause.  This  is  done 
by  regulation  of  the  diet.  While  the  cause  is  being  removed,  the 
symptoms  must,  however,  be  relieved,  if  possible.  It  is  advisable 
to  try  the  simplest  remedies  first.  These  are  hot  applications  to  the 
abdomen  and  hot  water  by  the  mouth.  If  these  measures  are  not 
effective,  a  quarter  or  a  half  of  a  soda  mint  tablet  dissolved  in  an 
ounce  of  hot  water  may  be  tried,  or  from  two  to  five  drops  of  the 
essence  of  peppermint  in  the  same  amount  of  hot  water.  Five  or 
ten  drop  doses  of  the  elixir  of  catnip  and  fennel  (Wyeth's)  in  one  or 
two  tablespoonfuls  of  hot  water  are  sometimes  useful.  An  enema 
of  warm  water  will  almost  always  stop  the  colic  if  other  measures 
fail.  It  is  very  seldom  necessary  or  advisable  to  use  any  form  of 
alcohol  or  paregoric.  Flatulence  and  colic  are  often  due  to  the 
swallowing  of  air  during  the  act  of  nursing,  whether  from  the 
breast  or  bottle.  The  swallowed  air  tends  to  collect  in  the  fundus. 
After  the  stomach  is  partially  full  the  air  cannot  reach  and  be 
discharged  through  the  cardiac  orifice.  If  the  baby  is  picked  up 
from  time  to  time  during  the  nursing,  held  upright  and  its  back 
patted,  the  air  can  escape  and  the  flatulence  and  colic  will  be  pre- 
vented. 

There  is  little  or  no  place  for  the  so-called  "digestants"  in  the 
treatment  of  disturbances  of  digestion  in  infancy.  There  is  almost 
never  a  deficiency  of  either  pepsin  or  hydrochloric  acid  in  the  gas- 
tric secretion  and  rennin  is  always  present.  The  panreatic  fer- 
ments cannot  pass  through  the  stomach  without  being  destroyed. 
The  only  place  for  the  digestive  ferments  in  the  treatment  of  these 


290  MEDICINAL  TREATMENT 

conditions  is,  therefore,  in  predigesting  the  foods  before  they  are 
taken  by  the  infant. 

There  is  little  or  no  absorption  of  fat  through  the  skin,  certainly 
not  enough  to  have  any  appreciable  effect  on  the  nutrition.  The 
only  way  in  which  inunctions  of  cod  liver  or  other  oils  in  chronic 
disturbances  of  nutrition  can  be  of  use,  therefore,  is  through  the 
stimulation  of  the  peripheral  circulation  and  muscular  tone  in- 
cident to  the  rubbing. 

It  is  advisable  to  stop  the  food  entirely  for  from  twelve  to  forty- 
eight  hours  in  all  the  acute  disturbances  of  digestion  from  whatever 
cause.  There  is  no  danger  in  stopping  the  food,  if  the  baby  is  given 
as  much  water  as  it  would  take  of  food.  Babies  can  get  along  very 
well  for  a  time  without  food,  but  they  cannot  get  on  without  water. 
If  they  object  to  plain  water,  they  will  usually  take  it  gladly  if  it  is 
sweetened  with  saccharin.  There  is  no  objection  to  giving  it  in  the 
form  of  very  weak  tea,  sweetened  with  saccharin,  if  the  babies  like 
it  better  in  this  way.  The  length  of  time  during  which  food  is 
withheld  depends  on  the  severity  of  the  symptoms  in  the  given 
case. 

Great  care  must  be  exercised  in  stopping  the  food  of  babies 
suffering  from  chronic  disturbances  of  the  nutrition,  even  when 
there  is  an  acute  exacerbation  of  the  symptoms.  Such  babies  are 
in  no  condition  to  bear  acute  starvation  on  top  of  a  chronic  inani- 
tion. In  fact,  the  complete  withdrawal  of  food  is  very  likely  to 
kill  them.  It  is  much  wiser,  therefore,  under  these  conditions,  to 
weaken  or  change  the  food  than  to  stop  it  entirely. 


CHAPTER  XXIV 
INDIGESTION  WITH  FERMENTATION 

The  term,  indigestion  with  fermentation,  is  used  to  distinguish  a 
condition  in  which  fermentation  takes  place  in  the  intestines  as  the 
result  of  the  abnormal  growth  and  activity  of  microorganisms  in  the 
intestinal  contents.  The  term  fermentation  is  used  here  in  its 
broad  sense  and  includes  all  the  changes  which  take  place  in  the 
various  food  elements  as  the  result  of  the  action  of  microorganisms 
upon  them.  In  some  instances  the  microorganisms  concerned  are 
the  normal  inhabitants  of  the  intestinal  tract,  in  others  they  do  not 
belong  to  the  normal  intestinal  flora. 

It  is  extremely  difficult  to  draw  a  distinct  line  between  simple 
indigestion  and  indigestion  with  fermentation  on  the  one  hand  and 
between  indigestion  with  fermentation  and  infectious  diarrhea  on 
the  other.  It  is  assumed  in  the  first  instance  that  there  is  no 
fermentation  in  simple  indigestion.  This  assumption  is,  of  course, 
not  strictly  true,  because  there  is  imquestionably  a  certain  amount 
of  fermentation  under  normal  conditions  and  more  in  simple  in- 
digestion. In  simple  indigestion,  however,  the  fermentation  plays 
but  a  small  part  in  either  the  pathology  or  symptomatology  of  the 
condition  and  none  in  the  etiology.  In  indigestion  with  fermenta- 
tion, however,  fermentation  plays  the  major  role.  Whether  the 
abnormal  bacterical  activity  develops  secondarily  as  the  result  of 
disturbances  of  the  normal  processes  of  digestion  or  appears 
primarily  as  the  result  of  the  introduction  of  an  excessive  number 
of  bacteria,  whether  or  not  they  are  members  of  the  ordinary  iatea- 
tinal  bacterial  flora,  into  the  intestine  or  as  the  result  of  a  change  in 
the  normal  relations  of  the  bacteria  to  each  other  from  a  badly  bal- 
anced diet,  the  symptoms  are  due  in  the  main  to  the  presence  of  the 
abnormal  products  of  bacterial  activity.  It  is  assumed  hi  the 
second  instance  that  in  indigestion  with  fermentation  there  are  no 
pathological  lesions  in  the  intestinal  wall  and  that  no  micro- 
organisms pass  from  the  intestines  into  the  general  circulation. 
These  assumptions  are  also  not  strictly  true,  because  there  are, 
without  doubt,  some  minor  changes  in  the  intestinal  wall  in  severe 
cases  of  indigestion  with  fermentation  and  it  is  presumable  that 
an  occasional  microorganism  enters  the  blood  stream.     The  in- 

291 


292  ETIOLOGY 

testinal  lesions  are,  however,  never  marked,  in  contradistinction 
to  the  severe  lesions  characteristic  of  infectious  diarrhea.  It  is 
presumable,  moreover,  although  not  proven,  that  in  infectious 
diarrhea  microorganisms  frequently  pass  into  the  circulation,  per- 
haps in  considerable  numbers. 

Etiology. — So  little  is  known  accurately  as  to  the  normal  intes- 
tinal flora  and  as  to  the  normal  variations  in  the  relation  of  the  in- 
dividual elements  of  this  flora  to  each  other  as  the  result  of  changes 
in  the  relative  proportions  of  the  various  food  elements,  that  it 
is  extremely  difficult  to  draw  any  positive  conclusions  from  the 
microscopic  examination  of  the  stools,  not  only  as  to  what  organ- 
ism or  organisms  are  causing  the  trouble  in  a  given  case,  but  also 
as  to  what  organisms  may  in  general  cause  excessive  fermentative 
changes.  Furthermore,  it  is  by  no  means  always  safe  to  draw  posi- 
tive conclusions  as  to  the  intestinal  bacteria  from  an  examination  of 
the  fecal  bacteria.  There  is  a  certain  amount  of  fairly  satisfactory 
evidence  to  show  that  butyric  acid  bacilli,  the  B.  acidophilus,  and 
the  B.  putrificus  may  cause  abnormal  fermentative  changes  in 
the  intestinal  contents.  It  is  probable  that  under  certain  condi- 
tions the  colon  bacillus  may  also  be  the  cause  of  abnormal  fer- 
mentative processes.  The  unrestrained  and  excessive  activity  of 
the  normal  lactic  acid  forming  organisms  of  the  intestinal  flora  may 
also  result  in  an  excessive  acid  fermentation  sufficient  to  cause  def- 
inite and  severe  symptoms.  The  B.  perfringens,  described  by  Tis- 
sier  ^  has  been  proved  more  positively  than  any  other  organism  to 
be  the  cause  of  fermentative  diarrhea. 

Pathology. — The  pathological  changes  in  the  intestine  in  indiges- 
tion with  fermentation  are  comparatively  slight.  In  most  in- 
stances there  is  presumably  nothing  more  than  an  injection  of  the 
mucous  membrane,  while  in  the  most  severe  cases  the  process  does 
not  progress  beyond  that  of  a  mild  catarrhal  inflammation. 

In  the  more  severe  cases  of  indigestion  with  fermentation  there 
are  more  or  less  marked  degenerative  changes  in  the  parenchy- 
matous organs,  especially  in  the  liver  and  kidneys.  True  inflam- 
mation of  the  kidneys  is,  however,  uncommon.  Secondary  infec- 
tions of  other  organs,  such  as  the  middle  ears  and  lungs,  as  the 
result  of  the  general  weakened  resistance,  are  not  uncommon  in 
the  serious  cases. 

Symptomatology. — Indigestion  with  fermentation  is  more  often 

acute  than  chronic.    When  it  is  acute,  there  is  in  most  instances 

some  elevation  of  the  temperature.    The  height  of  the  temperature 

depends  presumably  on  the  amount  of  toxic  absorption.    In  the 

^Annales  de  I'Institut  Pasteur,   1905,  sdx,  273. 


SYMPTOMATOLOGY  293 

most  severe  cases  it  may  be  as  high  as  104**  F.  or  105°  F.,  or  even 
higher.  Such  high  temperatures  do  not,  however,  usually  last 
more  than  three  or  four  days,  although  the  temperature  may  be 
moderately  elevated  for  some  days  longer.  The  temperature  is 
ordinarily  but  Uttle,  if  at  all,  elevated  in  the  chronic  cases. 

The  appetite  is  usually  impaired.  Vomiting  is  unusual,  and 
there  is  nothing  characteristic  about  it,  when  it  does  occur.  There 
is  usually  more  or  less  abdominal  discomfort,  and  the  abdomen  is 
not  infrequently  distended.  There  is,  of  course,  always  more  or 
less  loss  of  weight. 

Diarrhea  is  a  marked  symptom  in  almost  all  cases  of  indigestion 
with  fermentation.  The  character  of  the  stools  depends  upon 
which  of  the  food  elements  is  being  attacked  by  the  microorgan- 
isms which  are  the  cause  of  the  trouble  in  the  individual  case. 
In  the  vast  majority  of  instances  indigestion  with  fermentation  is 
due  to  organisms  which  produce  fermentative  changes  in  carbo- 
hydrates and  to  a  less  extent  in  fats.  The  stools  are,  therefore, 
usually  green  in  color,  strongly  acid  in  reaction  and  odor,  and  ir- 
ritating to  the  skin.  They  often  contain  a  considerable  amount  of 
mucus,  as  the  result  of  the  irritation  of  the  intestinal  mucosa  by 
the  highly  acid  intestinal  contents.  They  are  often  frothy  and  not 
infrequently  contain  many  small,  soft,  fat  curds.  When  the  dis- 
ease is  caused  by  the  abnormal  activity  of  proteolytic  organisms 
the  stools  are  more  often  yellow  or  yellowish-brown  than  green. 
They  are  ordinarily  alkaline  in  reaction  and  have  a  foul  odor.  They 
seldom  contain  curds,  and  mucus  is  a  less  prominent  constituent. 
In  one  type  of  this  class  of  cases  the  stools  are  rather  character- 
istic, being  frequent,  small,  watery,  dark-brown,  alkaline  and  with 
a  peculiar  musty  odor. 

There  is  almost  always  a  moderate  polynuclear  leucocytosis  in 
these  cases,  if  they  are  at  all  severe.  It  is  ordinarily  not  over 
20,000,  but  in  the  severest  cases  may  be  much  higher.  In  them, 
however,  the  toxemia  may  be  so  great  that  the  system  is  over- 
whelmed.   In  such  instances  there  is  no  leucocytosis. 

The  urine  is  usually  diminished  as  the  result  of  the  loss  of  fluid 
through  the  bowels  and  the  diminution  in  the  intake.  In  the  se- 
vere cases  it  not  infrequently  shows  the  evidences  of  acute  degen- 
eration of  the  kidneys.  Acute  inflammation  of  the  kidneys  is  very 
unusual.  The  urine  rarely  contains  sugar,  unless  the  toxemia  is 
extreme  or  very  large  amounts  of  sugar  are  being  ingested. 

In  the  most  severe  and  fatal  cases  certain  symptoms,  such  as  un- 
controllable vomiting,  marked  prostration  and  hyperpyrexia,  are 
likely  to  develop.    In  others  there  may  be  marked  symptoms  of  ir- 


294  DIAGNOSIS 

ritation  of  the  nervous  system.  These  sjmiptoms  are  in  all  prob- 
ability due  largely  to  toxic  absorption  from  the  intestines.  They 
are  more  fully  described  in  the  chapter  on  Infectious  Diarrhea,  in 
which  disease  they  also  frequently  develop. 

Diagnosis. — The  two  conditions  with  which  indigestion  with 
fermentation  may  be  confused  are  simple  indigestion  and  infectious 
diarrhea.  It  is  often  very  difficult  to  distinguish  between  simple 
indigestion  and  indigestion  with  fermentation,  because  of  the  fact 
that  all  but  the  mildest  cases  of  simple  indigestion  are  accom- 
panied by  a  certain  amount  of  fermentation  in  the  intestinal  con- 
tents as  the  result  of  bacterial  activity  in  them.  The  border  hne 
between  them  is,  therefore,  a  very  indefinite  one  and  must  often 
be  arbitrarily  drawn.  The  manifestations  of  simple  indigestion  of 
the  various  food  elements  are,  moreover,  very  similar  to  those  of 
fermentation  of  these  same  elements  as  the  result  of  abnormal  bac- 
terial action.  This  makes  it  still  more  difficult  to  draw  the  fine. 
It  has  to  be  drawn  principally  on  the  relative  severity  of  the  symp- 
toms in  general  and  especially  on  the  degree  of  the  evidences  of 
fermentation.  When  these  predominate  the  picture,  the  diagnosis 
of  indigestion  with  fermentation  is  justified.  In  general,  moreover, 
the  constitutional  symptoms  are  more  severe,  the  temperature 
higher,  and  the  manifestations  of  toxemia  more  marked  in  indiges- 
tion with  fermentation  than  in  simple  indigestion. 

Mild  OP  moderately  severe  cases  of  indigestion  with  fermenta- 
tion are  not  likely  to  be  confused  with  infectious  diarrhea.  The 
more  severe  cases,  with  high  fever,  marked  evidences  of  toxic  ab- 
sorption and  considerable  amounts  of  mucus  in  the  stools  may,  how- 
ever, be  mistaken  for  it.  It  is  very  often  difficult  to  differentiate 
between  them  and  it  is  not  infrequently  impossible  to  make  a  posi- 
tive diagnosis.  The  most  important  single  symptom  in  the  di- 
agnosis is  probably  the  temperature  curve,  the  elevation  of  tem- 
perature in  severe  cases  of  indigestion  with  fermentation  being,  as 
a  rule,  high  and  of  short  duration,  while  in  infectious  diarrhea,  al- 
though not  usually  very  high,  it  is  constant  and  continuous.  The 
stools  show,  in  general,  more  evidences  of  fermentation  in  indiges- 
tion with  fermentation  than  in  infectious  diarrhea,  and  never 
contain  blood,  as  they  do  in  infectious  diarrhea.  In  a  certain 
number  of  instances,  however,  a  positive  diagnosis  can  only  be 
made  by  a  bacteriological  examination  of  the  stools. 

Prognosis. — The  outlook  is  always  grave  in  the  cases  which 
show  marked  evidences  of  toxic  absorption.  If  they  survive  the 
first  three  or  four  days,  however,  they  usually  recover.  Those 
cases  in  which  the  stools  are  watery  and  dark  brown  with  a  musty 


TREATMENT  295 

odor  are  also  always  serious.  The  cases  in  which  the  evidences  of 
carbohydrate  fermentation  predominate  are  usually  milder  than 
the  other  types  and  yield  fairly  readily  to  rational  treatment.  A 
high  temperature  is  not,  of  itself,  of  especially  bad  prognostic  im- 
port. Neither  are  the  presence  of  considerable  amounts  of  mucus 
in  the  stools  or  of  albumin  and  other  evidences  of  degeneration  of 
the  kidneys  in  the  urine.  The  cases  which  have  become  chronic 
are  likely  to  drag  along  for  a  long  time  in  spite  of  careful  treatment. 

Treatment. — It  is  advisable  in  all  acute  cases  of  indigestion  with 
fermentation  to  at  once  thoroughly  clean  out  the  intestinal  tract. 
The  best  drug  for  this  purpose  is  castor  oil.  It  works  quickly, 
thoroughly  and  causes  less  irritation  of  the  intestines  than  other 
cathartics.  The  dose  should  not  be  less  than  two  teaspoonfuls. 
It  should  be  given  plain.  If  the  castor  oil  is  vomited,  calomel 
should  be  given  in  its  place.  The  usual  dose  is  yV  of  ^  grain,  com- 
bined with  one  grain  of  bicarbonate  of  soda,  every  half-hour  until 
1  or  \]/2  grains  have  been  given.  It  is  wise  to  follow  it  with  two  or 
three  teaspoonfuls  of  the  milk  of  magnesia  in  two  or  three  hours 
after  the  last  dose.  This  treatment  should  be  repeated,  if  the 
desired  results  are  not  obtained. 

All  food  should  be  stopped  for  from  twelve  to  twenty-four  hours. 
It  is  not  desirable,  as  a  rule,  to  withhold  food  longer  than  this.  It  is 
necessary,  however,  to  give  water  freely  during  this  period,  be- 
cause, although  a  baby  can  bear  temporary  starvation,  it  cannot 
get  along  without  water.  At  least  as  much  water  should  be  given 
as  the  baby  would  ordinarily  take  of  liquid  in  the  form  of  food  in 
the  given  time.  The  water  may  be  given  either  warm  or  cool, 
and  may  be  sweetened  with  saccharin,  if  desired.  There  is  no 
objection  to  giving  it  in  the  form  of  weak  tea,  sweetened  with 
saccharin,  if  it  is  taken  better  in  this  way.  It  should  be  given 
through  a  tube,  if  the  baby  will  not  take  it  otherwise.  It  is  not 
safe  to  continue  the  period  of  starvation  longer  than  twenty-four 
hours  when  the  microorganisms  which  are  causing  the  trouble  are 
of  the  proteolytic  type,  because  the  intestinal  secretions  are  protein 
in  nature  and,  therefore,  provide  a  suitable  culture  medium  for 
proteolytic  bacteria.  There  is  no  objection  to  a  longer  period  of 
starvation  when  the  microorganisms  are  of  the  types  which  thrive 
on  fats  and  carbohydrates,  if  it  is  for  any  reason  indicated.  Pre- 
hminary  purgation  and  starvation  are  rarely  advisable  in  chronic 
cases. 

The  object  to  be  aimed  at  in  the  treatment  of  indigestion  with 
fermentation  is  the  destruction,  or  at  least  the  inhibition  of  the 
activity,  of  the  microorganisms  which  are  the  cause  of  the  disease. 


296  TREATMENT 

It  is  useless  to  attempt  to  do  this  by  the  administration  of  drugs  by 
the  mouth,  because  it  is  impossible  to  give  any  of  the  so-called 
intestinal  antiseptics  in  large  enough  doses  to  have  any  effect  on 
the  pathogenic  bacteria  in  the  intestine  without  poisoning  the 
baby.  If  they  did  have  any  action,  it  would  be  exerted,  moreover, 
on  the  antagonistic  as  well  as  on  the  pathogenic  bacteria.  They 
would  be  likely,  therefore,  to  do  as  much  harm  as  good.  It  is 
possible  that  the  salts  of  bismuth  may  diminish  the  intensity  of  the 
symptoms  to  a  small  extent.  They  do  not  have,  however,  any 
curative  action.  If  they  are  used,  they  should  be  given  in  doses  of 
from  ten  to  twenty  grains,  every  two  hours.  It  is  safer  to  use  the 
subcarbonate  or  the  milk  of  bismuth  than  the  subnitrate,  because 
of  the  danger  of  nitrite  poisoning  when  the  subnitrate  is  used.  It 
is  also  useless  to  attempt  to  get  rid  of  the  pathogenic  bacteria  by 
irrigation  of  the  bowels,  because  the  fluid  used  in  irrigation  never 
reaches  higher  than  the  ileocaecal  valve,  if  it  reaches  as  far  as  that, 
while  the  chief  seat  of  the  trouble  is  in  the  small  intestine. 

It  is  possible  in  some  instances  to  destroy  the  pathogenic  micro- 
organisms, or  at  any  rate  to  materially  diminish  their  numbers 
and  inhibit  their  activity,  by  the  administration  of  antago- 
nistic bacteria.  This  method  has  been  proved  to  be  effectual  when 
the  disturbance  is  due  to  the  B.  perfringens  and  organisms  of  the 
gas  bacillus  group.  There  is  some  evidence  to  show  that  it  is  of 
value  when  the  trouble  is  caused  by  the  B.  acidophilus  and  proteo- 
lytic organisms.  Tissier  has  shown  that  the  B.  bifidus  has  an 
antagonistic  action  on  the  B.  perfringens.  It  is  probable  that  it  has 
a  similar  action  on  other  pathogenic  organisms.  It  is,  however, 
anaerobic  and,  therefore,  difficult  of  cultivation.  Its  use  is,  on  this 
account,  hardly  practicable  clinically.  Lactic  acid  bacilli  have, 
however,  an  antagonistic  action  on  all  the  organisms  mentioned. 
It  is  easy  to  obtain  them  in  pure  cultures  and  in  any  amounts 
desired.  It  is  probable  that  the  Bulgarian  bacillus  has  some  ad- 
vantages over  the  other  varieties.  The  lactic  acid  bacilli  may  be 
given  in  the  form  of  broth  cultures,  in  the  form  of  buttermilk  or  in 
the  form  of  modified  milk  ripened  by  them.  They  are  effective 
when  given  in  any  of  these  ways.  It  seems  most  rational,  however, 
to  give  them  in  the  form  of  ripened  modified  milk,  because  when 
given  in  this  way  the  food  can  also  be  modified  to  suit  the  needs  of 
the  individual  infant.  There  is  a  certain  advantage  in  the  use  of 
buttermilk  and  ripened  modified  milk  over  broth  cultures  of  the 
lactic  acid  bacilli,  in  that  they  contain,  in  addition  to  the  organ- 
isms, lactic  acid  which  has  been  formed  by  them.  This,  in  itself, 
has  an  antagonistic  action  on  the  growth  of  the  pathogenic  organ- 


TREATMENT  297 

isms.  When  buttermilk  and  ripened  modified  milk  are  used  in 
the  treatment  of  indigestion  with  fermentation,  they  should  not  be 
pasteurized  or  boiled,  because,  if  they  are,  the  lactic  acid  organ- 
isms are  killed  and  can,  therefore,  have  no  effect.  It  is  self- 
evident  that,  when  lactic  acid  bacilli  are  the  cause  of  the  fermenta- 
tion, foods  containing  these  organisms  should  not  be  given. 

Another  way  by  which  the  number  of  the  organisms  causing 
indigestion  with  fermentation  can  be  diminished  and  their  activity 
inhibited  is  by  a  change  in  the  character  of  the  infant's  food.  A 
change  in  the  character  of  the  food  results  in  a  change  in  the 
character  of  the  intestinal  contents,  that  is,  in  the  medium  in  which 
the  pathogenic  organisms  are  growing.  If  these  are  of  the  types 
which  thrive  on  a  carbohydrate  medium,  the  percentages  of  the 
carbohydrates  should  be  diminished  and  that  of  the  protein  in- 
creased. The  percentage  of  fat  should  also  be  diminished,  because 
when  there  is  an  abnormal  fermentation  of  the  carbohydrates  there 
is  very  likely  to  be  a  secondary  fermentation  of  the  fat.  When  the 
organisms  are  of  the  butyric  acid  forming  type  the  percentage  of  fat 
should  be  much  diminished,  that  of  the  carbohydrates  diminished 
to  a  moderate  degree  and  that  of  the  protein  increased.  When  the 
organisms  are  proteolytic,  the  percentage  of  protein  should  be 
diminished  and  that  of  the  carbohydrates  increased.  The  general 
principles  to  be  followed  as  to  the  choice  of  carbohydrates  in  dis- 
turbances of  the  digestion  which  have  been  described  in  the  chapter 
on  indigestion  are  equally  applicable  in  the  treatment  of  indiges- 
tion with  fermentation.  It  is  evident  that  in  certain  instances  it  is 
possible  to  combine  both  methods  of  treatment. 

Sisson  ^  has  come  to  the  conclusion,  however,  as  the  result  of 
his  experiments  on  puppies,  that  it  is  not  possible  to  change  the 
character  of  the  intestinal  flora  by  changes  in  the  diet.  Rettger  ^ 
has  arrived  at  a  different  conclusion,  as  have  also  previous  investi- 
gators. It  hardly  seems  wise,  therefore,  to  accept  Sisson's  results 
until  they  have  been  verified  by  others. 

Clinically,  when  the  stools  are  loose,  green,  acid  and  irritating, 
the  percentage  of  fat  and  carbohydrates  in  the  food  should  be  re- 
duced and  that  of  the  protein  raised.  It  is'in  cases  of  this  type  that 
"albumen  milk"  gives  such  satisfactory  results.  So  also  do  mix- 
tures made  with  a  high  percentage  cream  and  dried  casein.  Beef 
juice,  broths  and  albumen  water  may  also  be  given.  When  a  for- 
eign protein  is  given  under  these  conditions,  there  is  always  a  pos- 
sibility that  it  may  pass  through  the  intestinal  wall  imchanged  and 

»  Sisson:  Amer.  Jour.  Dis.  Child.,  1917,  xiii,  117. 
*  Rettger:  Jour.  Exp.  Med.,  1915,  xxi,  365. 


298  TREATMENT 

sensitize  the  baby.  This  is  especially  liable  to  happen  with  ^g 
albumen.  Albumen  water  should,  therefore,  always  be  used  cau- 
tiously, if  at  all,  in  the  treatment  of  the  diarrheal  diseases  of  in- 
fancy. Unless  the  fermentation  is  due  to  lactic  acid  bacilli, 
buttermilk  and  ripened  modified  milk  mixtures,  containing  low 
percentages  of  fat  and  carbohydrates  and  a  high  percentage  of  pro- 
tein, give  better  results  than  similar  modifications  unripened.  If 
the  fermentation  is  due  to  the  lactic  acid  bacilli,  the  simple  modi- 
fications give,  of  course,  much  more  satisfactory  results. 

When  the  stools  are  brownish,  alkaline  and  foul,  the  percentage 
of  protein  should  be  much  reduced  and  that  of  the  carbohydrates 
much  increased.  That  of  the  fat  should  be  kept  low.  Protein 
foods,  such  as  beef  juice,  broth  and  albumen  water  should  not  be 
given.  Buttermilk  and  ripened  modified  milk  mixtures  containing 
a  low  percentage  of  fat  and  protein  and  high  percentages  of  car- 
bohydrates usually  give  good  results.    So  also  does  breast-milk. 

Babies  that  are  seriously  ill  with  indigestion  with  fermentation 
are  very  likely  to  show  one  or  more  rather  characteristic  symptoms 
or  groups  of  symptoms.  One  of  these  groups  of  symptoms  almost 
invariably  develops  toward  the  end  in  fatal  cases.  These  symp- 
toms are: 

(a)  Excessive  vomiting. 

(b)  Hyperpyrexia. 

(c)  Symptoms  of  irritation  of  the  central  nervous  system. 

(d)  Prostration  and  collapse. 

It  is  probable  that  these  symptoms  are  chiefly  manifestations  of 
toxemia.  It  is  presumable  that  the  loss  of  water  through  the 
bowels  also  plays  a  part  in  their  production.  These  symptoms  also 
develop  very  frequently  in  infectious  diarrhea.  They  and  the 
treatment  for  them  are  fully  described  in  the  chapter  on  this 
disease.  So  also  are  the  use  of  salt  solution  and  stimulants  in 
serious  cases  of  diarrheal  disease. 

INTESTINAL  TOXEMIA   OF  THE   NEW-BORN 

This  condition,  although  not  a  very  uncommon  one,  is  often 
overlooked  or  mistaken  for  some  other  disease.  Being  in  all 
probability  due  to  bacterial  infection  of  the  retained  meconium  and 
the  absorption  of  the  toxic  products  formed  by  them  in  the  meco- 
nium, it  seems  more  rational  to  consider  it  under  the  head  of  indi- 
gestion with  fermentation  than  elsewhere.  There  are  no  data  as  to 
the  nature  of  the  causative  organisms  or  the  pathological  changes. 
The  clinical  picture  is  as  follows: 


INTESTINAL  TOXEMIA  OF  NEW-BORN  299 

Symptomatology. — ^A  baby  that  was  normal  at  birth,  and  has 
continued  to  seem  normal  and  to  do  well  up  to  the  second,  third, 
fourth  or  even  fifth  day,  becomes  rather  suddenly  ill.  He  is  likely 
to  cry  and  moan  considerably,  although  he  is  not  infrequently 
unusually  quiet.  Attacks  of  cyanosis  are  a  common  and  early 
symptom.  Twitching  of  the  extremities,  shght  general  rigidity 
and  retraction  of  the  head  come  on  in  many  instances,  while  con- 
vulsions are  not  infrequent.  The  temperature  is,  as  a  rule,  only 
moderately  raised,  but  may  be  high.  In  the  more  severe  cases  the 
baby  refuses  to  nurse.  Vomiting  is  uncommon.  In  most  instances 
there  is  no  diarrhea;  in  fact,  the  tendency  is  to  constipation.  The 
symptoms  develop  in  the  majority  of  instances  before  the  baby  has 
ceased  to  pass  meconium  and  it  is  very  common  to  find  that  it  has 
not  passed  as  much  as  the  average  baby.  If  the  stools  are  not 
composed  of  meconium,  they  are  usually  small  in  amount,  loose, 
dark-brown  and  contain  small,  soft  curds  and  mucus.  They  are 
often  offensive.  The  abdomen  may  be  distended,  but  usually  is 
not.  Loss  of  weight  is  generally  rapid,  the  face  becomes  pinched 
and  in  all  but  the  mildest  cases  it  is  evident  that  the  baby  is 
seriously  ill.  If  the  bowels  are  throughly  cleaned  out,  all  food 
stopped  for  a  time  and  water  given  freely^  recovery  is  usually  rapid 
and  complete.  If  the  bowels  are  not  cleaned  out  and  food  is 
continued,  a  fatal  termination  is  not  uncommon  and  recovery  is,  in 
any  event,  slow. 

Etiology. — ^The  most  reasonable  explanation  as  to  the  etiology  of 
these  cases  is  that  a  bacterial  infection  of  the  meconium,  through 
either  the  mouth  or  anus,  takes  place  within  the  first  twenty-four 
or  forty-eight  hours  after  birth;  that  on  account  of  the  incomplete 
evacuation  of  the  intestines  the  toxic  products  formed  in  the 
meconium  as  the  result  of  this  infection  are  absorbed  into  the  cir- 
culation and  that  these  toxic  products  cause  the  symptoms. 
Corroborative  evidence  in  favor  of  this  conception  is  that,  as  the 
meconium  is  made  up  of  protein,  the  products  of  bacterial  action  in 
it  must  necessarily  be  putrefactive  in  character  and,  therefore, 
toxic.  It  is  a  well-known  fact,  moreover,  that  cyanosis  may  be 
enterogenous  in  origin.  It  may  be  asked  why  this  symptom- 
complex  is  not  merely  a  manifestation  of  septic  infection,  that  is, 
of  the  entrance  of  bacteria  into  the  circulation.  It  is  impossible  to 
state  positively  that  this  is  not  the  case,  because  no  blood  cultures 
have  been  made  in  these  patients.  The  early  onset  of  the  symp- 
toms, the  absence  of  any  nidus  of  infection  and  the  absence  of 
other  signs  of  sepsis,  such  as  hemorrhages,  marked  jaundice  and 
boils,  make  it  improbable,  while  the  rapid  and  complete  recovery 


300  INDIGESTION  WITH  FERMENTATION 

after  the  evacuation  of  the  bowels  seems  sufficient  to  exclude  it. 
It  may  also  be  asked  why  it  is  not  simply  a  manifestation  of  starva- 
tion, analogous  to  the  so-called  "inanition  fever."  The  answer  is 
that  it  occurs  both  in  babies  that  have  not  been  fed  and  in  those 
that  have  been,  and  that  the  withdrawal  of  food  in  connection 
with  the  evacuation  of  the  bowels  relieves  it.    • 

Diagnosis. — The  diseases  for  which  this  condition  is  most 
likely  to  be  mistaken  are  cerebral  hemorrhage  as  the  result  of 
injury  at  birth,  meningitis,  hemorrhagic  disease  of  the  new-bom 
and  septic  infection  of  the  new-bom.  The  diagnosis  from  septic 
infection  of  the  new-bom  is  the  most  difficult.  The  symptoms  ap- 
pear earlier,  as  a  rule,  than  do  those  of  septic  infection  and  the 
temperature  is  usually  lower  than  in  sepsis.  There  is  no  local 
nidus  of  infection,  and  marked  general  and  local  sjonptoms  of 
infection,  such  as  hemorrhages,  deep  jaundice  and  furuncles,  are 
absent.  There  is  a  tendency  to  constipation  and  the  stools  are 
usually  meconium-like  in  character.  In  many  instances  it  is, 
however,  impossible  to  make  a  positive  diagnosis  without  the 
therapeutic  test  of  free  catharsis.  Hemorrhagic  disease  of  the 
new-bom  can  be  excluded  on  the  absence  of  hemorrhages.  Men- 
ingitis is  extremely  rare  at  this  age  and,  when  it  occurs,  it  is  a 
part  of  a  general  septic  infection.  There  is  almost  invariably 
bulging  of  the  anterior  fontanelle  in  meningitis  and  usually  when 
there  is  a  cerebral  hemorrhage.  There  are  usually  symptoms  of 
focal  irritation  in  hemorrhage  and  often  blood  in  the  nose  and 
nasopharynx,  while  in  both  cerebral  hemorrhage  and  meningitis 
there  is  likely  to  be  spasm  of  the  extremities  and  exaggeration  of  the 
knee-jerks.  These  latter  symptoms,  as  well  as  other  sjnmptoms  of 
cerebral  irritation,  may,  however,  also  be  present  in  intestinal 
toxemia.  A  lumbar  puncture  will  settle  the  diagnosis  at  once  in  a 
doubtful  case. 

Prognosis. — The  prognosis  is  a  grave  one  in  all  but  the  mild 
cases,  unless  the  condition  is  properly  treated.  If  the  bowels  are 
throughly  cleaned  out  at  once  and  food  stopped  for  a  time,  re- 
covery is  usually  rapid. 

Treatment. — The  treatment  consists  in  the  administration  of  one 
or  two  teaspoonfuls  of  castor  oil,  the  withdrawal  of  food  for  from 
twelve  to  twenty-four  hours  and  the  feeding  of  water  or  water 
sweetened  with  saccharin.  It  is  also  well  to  irrigate  the  bowels  in 
the  beginning.  Bromide  or  stimulants,  such  as  strychnia  or 
caffein,  may  be  used,  if  necessary.  The  best  food,  after  the  period 
of  starvation,  is  human  milk,  plain  or  diluted,  according  to  the 
individual  baby's  condition.    Next  to  this,  a  mixture  of  cow's  milk. 


INDIGESTION  WITH  FERMENTATION  301 

low  in  fat,  high  in  milk  sugar  and  with  a  moderate  amount  ot 
proteins,  part  of  these  preferably  in  the  form  of  the  whey  proteins. 
A  mixture  containing  0.50%  of  fat,  5%  of  milk  sugar,  0.50%  of 
whey  protein  and  0.25%  of  casein  would  be  a  suitable  one.  It  is 
important  to  give  a  high  percentage  of  milk  sugar  in  order  to 
change  the  bacterial  activity  from  the  proteolytic  to  the  fermenta- 
tive type. 


CHAPTER  XXV 
INFECTIOUS  DIARRHEA 

The  border  line  between  indigestion  with  fermentation  and 
infectious  diarrhea  is  necessarily  a  very  indefinite  one.  The 
sjmnptoms  in  severe  cases  of  indigestion  with  fermentation  differ 
but  little  from  those  in  mild  cases  of  infectious  diarrhea.  In  both 
instances  toxic  substances,  resulting  from  bacterial  growth,  are 
absorbed  into  the  circulation  and  cause  similar  symptoms  and 
pathological  changes.  In  indigestion  with  fermentation,  however, 
the  bacteria  do  not  enter  the  intestinal  wall.  The  local  lesions  are, 
therefore,  relatively  insignificant.  In  infectious  diarrhea,  on  the 
other  hand,  the  bacteria  do  enter  the  intestinal  wall  and  produce 
definite  lesions  of  the  wall.  These  lesions  may  or  may  not  be 
severe.  It  is  probable  that  bacteria  very  seldom  pass  through  the 
intestinal  wall  and  enter  the  circulation  in  indigestion  with  fer- 
mentation. It  is  probable  that  they  often  pass  through  the  wall 
into  the  circulation  in  infectious  diarrhea.  In  indigestion  with 
fermentation  the  seat  of  bacterial  activity  is  primarily  and  almost 
exclusively  in  the  intestinal  contents,  while  in  infectious  diarrhea 
it  is  primarily  in  the  intestinal  wall  itself.  In  indigestion  with 
fermentation  bacteria  are  the  secondary  invaders  of  an  abnormal 
intestinal  content,  while  in  infectious  diarrhea  they  are  the  primary 
cause  of  the  disease.  These  distinctions  must  not,  however,  be 
regarded  as  absolute.  They  are,  nevertheless,  definite  enough  to 
serve  as  a  basis  for  classification  and  for  treatment. 

Etiology. — Infectious  diarrhea  is  more  common  in  hot  weather 
than  at  other  times  of  the  year.  The  action  of  heat  in  the  produc- 
tion of  the  disease  is  due  mainly  to  the  lowering  of  the  general 
resistance  to  infection  which  it  produces.  It  presumably  also 
favors  the  development  outside  of  the  body  of  the  microorganisms 
which  are  found  in  this  disease.  Microorganisms  are,  however,  the 
primary  cause  of  infectious  diarrhea.  The  microoj^anisms  which 
produce  this  disease  are  of  several  different  types.  They  may  be 
divided  roughly  into  three  main  classes: 

a.  The  dysentery  bacillus  in  all  its  forms. 

b.  The  gas  bacillus  and  similar  organisms. 

c.  Other  organisms,  of  which  the  most  important  are  strepto- 

cocci, the  colon  bacillus  and  the  bacillus  pyocyaneus. 

302 


PATHOLOGY  303 

The  symptoms  produced  by  these  different  types  of  organisms 
are  practically  identical.  It  is  usually  impossible  to  determine 
from  them  which  type  of  organism  is  causing  the  disturbance. 

Several  investigators  have  recently  claimed  that  the  gas  bacillus 
is  never  the  cause  of  infectious  diarrhea.^  Their  results  do  not 
seem  conclusive  enough,  however,  to  overthrow  the  work  of  Kend- 
all and  his  associates.^  Furthermore  the  results  of  treatment  based 
on  a  varied  etiology  seem  sufficient  to  prove  that  all  cases  are  not 
due  to  the  dysentery  bacillus. 

Pathology. — The  pathological  lesions  of  the  intestine  are  very 
varied.  There  may  be  only  a  catarrhal  inflammation.  In  other 
cases  there  are  also  superficial  ulcerations.  In  others  there  is  hy- 
perplasia of  the  solitary  follicles  and  Peyer's  patches.  In  many 
instances  ulceration  takes  the  place  of  the  hyperplasia  of  these 
structures.  In  still  others  a  pseudo-membrane  is  formed,  which 
may  involve  considerable  areas.  The  pathological  lesions  are  usu- 
ally limited  to  the  large  intestine  and  the  last  two  or  three  feet  of 
the  small  intestine.  They  are  ordinarily  most  marked  in  the  large 
intestine.  The  severity  of  the  symptoms  does  not  always  coincide 
with  the  severity  of  the  intestinal  lesions.  In  general,  however,  the 
symptoms  are  most  marked  in  the  cases  in  which  the  lesions  are 
the  most  serious. 

There  is  almost  invariably  a  hyperplasia  of  the  mesenteric 
lymph  nodes.  This  almost  never,  however,  goes  on  to  suppuration. 
There  are  always  more  or  less  marked  degenerative  changes  in  the 
parenchymatous  organs,  especially  in  the  liver  and  kidneys.  True 
inflammation  of  the  kidneys  is,  however,  uncommon.  Secondary 
infections  of  other  organs,  such  as  the  middle  ears  and  lungs,  by 
other  organisms  as  the  result  of  the  general  weakened  resistance, 
are  not  infrequent. 

Symptomatology. — The  onset  of  infectious  diarrhea  is  usually 
acute.  It  may  be  preceded  for  a  few  days  by  symptoms  of  indiges- 
tion, but  ordinarily  there  are  no  premonitory  symptoms.  The 
first  symptom  in  most  cases  is  diarrhea.  The  first  stools  are  made 
up  of  fecal  matter.  Mucus  and  blood  soon  appear,  however,  and 
after  a  few  hours  or  a  day  or  two,  the  stools  are  composed  almost 
entirely  of  mucus  and  blood.  Pus  is  seldom  visible  macroscop- 
ically  until  several  days  after  the  onset  and,  in  many  instances,  it 

*  Knox  and  Ford:  Bull.  Johns  Hopkins  Hosp.,  1915,  xxvi,  27;  Ten  Broeck 
and  Norbury:  Boston  Med.  and  Surg.  Journ.,  1915,  clxxiii,  280  and  1916, 
clxxiv,  785. 

*  Kendall:  Boston  Med.  and  Surg.  Journ.,  1915,  clxxii,  851;  Sylvester 
and  Hibben:  Archives  of  Pediatrics,  1915,  xxxii,  457. 


304  SYMPTOMATOLOGY 

is  never  seen.  It  can,  however,  almost  always  be  found  with  the 
microscope.  Membrance  is  also  present  in  the  severest  cases. 
The  mucus  is  often  stained  green  or  brown.  The  odor  of  the  stools, 
when  they  are  made  up  chiefly  of  mucus  and  blood,  is  very  slight, 
but  sometimes  resembles  that  of  wet  hay.  When  the  stools  con- 
tain much  pus  or  membrance,  as  the  result  of  deep  ulcerative  or 
gangrenous  processes  in  the  intestine,  the  odor  is  putrefactive  or 
gangrenous.  The  reaction  of  the  stools  is  variable,  but  in  most 
instances  it  is  somewhat  alkaline.  The  number  of  stools  is  large, 
twelve,  twenty-four,  or  even  more,  in  twenty-four  hours.  The 
stools  are  usually  small,  being  often  merely  a  stain  of  blood  and 
mucus.  In  a  general  way,  the  larger  the  number  of  stools,  the 
smaller  are  the  individual  stools. 

Pain  in  the  abdomen  and  tenesmus  are  early,  marked  and  severe 
symptoms.  Tenesmus  is  especially  troublesome  and  annoying  and 
often  keeps  the  baby  restless  and  disturbed  and  prevents  it  from 
getting  the  proper  amount  of  sleep.  Prolapse  of  the  rectum  is  not 
at  all  infrequent  as  the  result  of  the  straining. 

Vomiting  is  a  rather  infrequent  symptom  and  is  seldom  trouble- 
some. The  appetite  is  usually  much  impaired  and  there  is  not 
infrequently  the  greatest  distaste  for  food  of  any  sort. 

The  abdomen  is  sometimes  distended,  but  in  the  vast  majority 
of  instances  is  much  sunken.  There  is  almost  never  any  spasm  of 
the  abdominal  muscles.  There  is  sometimes  tenderness  over  the 
course  of  the  colon,  but  this  is  unusual.  There  is  usually  no  en- 
largement of  either  the  liver  or  of  the  spleen.  Slight  enlargement 
of  the  spleen  is,  however,  not  very  uncommon.  In  some  instances 
the  hver  becomes  very  large  and  this  enlargement  may  develop 
very  rapidly.  The  liver  will  sometimes  enlarge  enough  in  three  or 
four  days  to  reach  well  below  the  navel  and  to  the  anterior  superior 
spine] 

The  temperature  is  always  elevated  in  infectious  diarrhea.  It  is 
usually  only  moderate,  100°  F.  to  102°  F.,  but  may  be  several  de- 
grees higher.  It  is  more  likely  to  be  high  in  the  beginning  than 
later.  The  temperature  is  usually  a  fairly  constant  one  without 
marked  intermissions  or  remissions.  It  lasts  throughout  the  active 
stage  of  the  disease. 

The  symptoms  are,  however,  not  always  so  characteristic.  The 
number  of  stools  may  be  but  Uttle  increased,  mucus  and  blood  may 
be  scanty,  or  even  wanting,  and  tenesmus  absent.  The  sjmaptoms 
may  be,  in  fact,  precisely  like  those  of  severe  simple  indigestion 
or  of  indigestion  with  fermentation.  In  such  instances  the  con- 
tinued temperature  is  the  most  suggestive  sjonptom.    The  real 


SYMPTOMATOLOGY  309 

condition  can  only  be  recognized  in  such  instances,  however,  by  a 
bacteriological  "examination  of  the  stools. 

The  blood  almost  always  shows  a  moderate,  polynuclear  leuco- 
cytosis,  usually  somewhere  in  the  neighborhood  of  20,000.  It  may 
however,  be  much  higher.  In  the  severest  cases  in  which  the  toxe- 
mia is  extreme  and  the  system  is  unable  to  react,  there  may  be  no 
leucocytosis  or  even  a  leucopenia. 

The  urine  is  almost  invariably  diminished  as  the  result  of  the 
loss  of  fluid  through  the  bowels  and  the  diminution  in  the  intake. 
It  not  infrequently  shows  the  evidences  of  acute  degeneration  of 
the  kidneys.  Acute  inflammation  of  the  kidneys  is  very  unusual. 
The  urine  rarely  contains  sugar  unless  the  toxemia  is  extreme  or 
very  large  amounts  of  sugar  are  being  ingested. 

In  the  most  severe  and  fatal  cases,  certain  symptoms,  such  as 
uncontrollable  vomiting,  marked  prostration  and  hyperpyrexia, 
presumably  due  largely  to  toxic  absorption,  develop.  These  symp- 
toms may  also  develop  in  the  course  of  indigestion  with  fermen- 
tation. They  will  be  discussed  more  in  detail  later  and  the  treat- 
ment for  them  described  at  the  same  time. 

It  is  impossible  to  determine  from  the  symptoms  what  form  of 
organism  is  the  cause  of  the  disease  in  the  individual  case.  There  is 
nothing  about  the  stools  which  will  aid  in  the  differentiation  except, 
in  rare  instances,  the  peculiar  green  color  caused  by  the  bacillus 
pyocyaneus.  If  the  green  color  is  produced  by  this  organism,  it 
will  disappear  when  nitric  acid  is  added  to  the  stool.  If  it  is  due  to 
bile,  the  characteristic  color  of  GmeUn's  test  will  appear  when 
nitric  acid  is  added.  The  microscopic  examination  of  the  stools  is 
of  little  assistance  in  differentiating  the  various  types  unless  the 
streptococcus  is  the  cause,  in  which  case  it  is  usually  present  in 
large  numbers  and  easily  recognized.  The  presence  or  absence  of 
the  gas  bacillus  can  be  determined  in  from  eighteen  hours  to 
twenty-four  hours,  or  even  less,  by  the  following  method : 

This  method  is  a  simple  one,  which  can  be  easily  carried  out  by 
anyone.  A  small  portion  of  the  stool  is  added  to  a  test  tube  of 
milk.  The  infected  tube  is  then  gradually  brought  to  the  boiling 
point  of  water  in  a  water-bath  and  kept  there  for  three  minutes. 
In  this  way,  all  the  bacteria  not  in  the  spore  state  are  killed  and  the 
development  of  whatever  spores  may  be  present  into  vegetative 
cells  is  unrestrained  by  the  presence  of  non-spore-forming  organ- 
isms. The  tube  is  then  incubated  at  body  temperature  for  from 
eighteen  to  twenty-four  hours.  When  the  gas  bacillus  is  present, 
the  casein  is  largely  dissolved  (usually  at  least  80%) ;  the  resid- 
ual casein  is  somewhat  pinkish  in  color  and  filled  with  holes;  and 


306  TEST  FOR  GAS  BACILLUS 

the  odor  of  the  culture  is  much  Uke  that  of  rancid  butter,  as  the 
result  of  the  formation  of  butyric  acid  by  the  gas  bacillus.  Gram 
stained  preparations  made  from  the  milk  show  rather  thick,  short, 
Gram-positive  bacilli,  with  slightly  rounded  ends.  The  fermenta- 
tion is  more  easily  observed  if  the  milk,  after  being  boiled,  is  put 
in  a  sterile  fermentation  tube.  "Pseudo-reactions"  may  occur 
in  which  there  is  some  liquefaction  of  the  casein,  but  the  shotted 
appearance  of  the  residual  casein  is  absent  and  there  is  no  odor  of 
butyric  acid.^  The  following  method  is  also  simple  and  satisfac- 
tory: Fill  a  fermentation  tube  and  large  test  tube  with  concen- 
trated nitric  acid.  Pour  off  acid  after  three  minutes  and  rinse  with 
hot  tap  water  until  neutral  to  litmus.  With  a  glass  spatula,  also 
soaked  in  acid  and  washed  until  neutral,  place  about  one  c.  c,  of  dex- 
tri-maltose  and  one  c.  c.  of  stool  in  one-third  test  tube  of  water. 
Boil  vigorously  one-half  minute  and  pour  into  fermentation  tube, 
tilting  back  and  forth  to  eliminate  bubbles.  Stopper  tube  with 
flamed  cotton  and  place  in  incubator  at  37°  C.  for  twenty-four 
hours.  Then  inspect  tube  for  gas  and  note  amount.  If  no  gas  is 
formed  or  the  bubble  is  no  larger  than  a  pinhead,  the  result  is  nega- 
tive. If  there  is  less  than  one-half  inch  of  gas,  the  result  is  ques- 
tionable. If  there  is  one-half  inch  or  more  of  gas,  the  result  is  posi- 
tive.^ It  must  be  remembered,  however,  in  interpreting  the 
results  of  this  test,  that  the  presence  of  a  few  gas  bacilli  does  not 
necessarily  prove  that  they  are  the  cause  of  the  disease.  There  is, 
unfortunately,  no  method  for  determining  the  presence  or  absence 
of  dysentary  bacilli  that  does  not  require  special  inedia  and  a  fairly 
well  equipped  laboratory.  Baker  ^  has,  however,  recently  de- 
veloped an  intracutaneous  test  for  the  dysentery  bacillus  which 
gives  positive  results  in  from  six  to  eighteen  hours  and  which 
promises  to  be  most  useful. 

Diagnosis. — The  only  disease  with  which  a  typical  case  of  in- 
fectious diarrhea  is  likely  to  be  confused  is  intussusception.  It  is, 
however,  usually  not  difficult  to  differentiate  between  these  two 
conditions.  Intussusception  begins  acutely  with  pain  in  the  ab- 
domen and  evidences  of  shock,  the  stools  of  mucus  and  blood  not 
appearing  until  later.  The  onset  of  infectious  diarrhea  is  less  acute, 
pain  is  usually  not  present,  or,  if  so,  it  is  slight,  and  there  are  no 
symptoms  of  shock,  while  the  stools  of  mucus  and  blood  appear 
almost  at  once.    The  stools  contain  no  fecal  matter  in  intussuscep- 

^  See  Kendall  and  Smith:  Boston  Medical  and  Surgical  Journal,  1910, 
Vol.  clxiii,  578. 

2  Sylvester  and  Hibben:  Archives  of  Pediatrics,  1915,  xxxii,  457. 
'  Baker:  Journal  of  Immunology,  1917,  ii,  453. 


DIAGNOSIS  307 

tion,  while  they  usually  contain  some  in  infectious  diarrhea.  Fever 
is  common  to  both  diseases,  but  is  usually  higher  in  infectious  di- 
arrhea than  in  intussusception.  The  abdomen  is  almost  always 
sunken  in  infectious  diarrhea,  but  likely  to  be  somewhat  distended 
in  intussusception.  There  is  never  any  muscular  spasm  in  infec- 
tious diarrhea,  usually  some  in  intussusception.  There  may  be 
abdominal  tenderness  in  both  conditions.  It  is  seldom  marked  in 
either,  however,  and  is  not  of  importance  in  the  differential  diagno- 
sis. There  is  never  a  tumor  in  the  abdomen  or  rectum  in  infectious 
diarrhea,  while  there  often  is  one  in  intussusception.  The  absence 
of  a  tumor  does  not,  however,  rule  out  intussusception.  Both  con- 
ditions are  usually,  but  not  always,  accompanied  by  a  leucocy- 
tosis. 

Simple  indigestion  and  indigestion  with  fermentation  are  not 
likely  to  be  mistaken  for  infectious  diarrhea.  Mild  cases  of  in- 
fectious diarrhea  in  which  the  number  of  stools  is  not  very  large 
and  in  which  there  is  no  blood  and  relatively  little  mucus  in  the 
stools  are  very  likely,  on  the  other  hand,  to  be  mistaken  for  in- 
digestion with  fermentation.  Fever,  abdominal  discomfort,  ano- 
rexia, wasting  and  symptoms  of  toxic  absorption  are  conmion  to 
both  conditions.  These  symptoms  differ  only  in  degree  in  the 
two  diseases  and  may  be  more  marked  in  indigestion  with  fermen- 
tation than  in  mild  cases  of  infectious  diarrhea.  It  is  often  very 
difficult  to  differentiate  between  them  and  it  is  not  infrequently 
impossible  to  make  a  positive  diagnosis.  The  most  important 
single  symptom  in  the  diagnosis  is  probably  the  temperature  curve, 
the  elevation  of  temperature  in  digestion  with  fermentation  being 
ordinarily  either  very  slight  or  high  and  of  short  duration,  while 
in  infectious  diarrhea,  although  usually  not  very  high,  it  is  con- 
stant and  continuous.  In  many  instances  a  positive  diagnosis  can 
only  be  made  by  a  bacteriological  examination  of  the  stools.  An 
agglutination  reaction  is  usually  present  in  infectious  diarrhea  by 
the  end  of  the  first  week  or  a  little  later  when  the  disease  is  caused 
by  the  bacillus  of  dysentery.  This  reaction  is,  however,  of  but 
little  practical  importance. 

When  the  temperature  is  high  and  the  symptoms  of  cerebral 
irritation  are  marked  and  develop  before  the  appearance  of  the 
characteristic  stools,  as  they  sometimes  do,  the  disease  may  be 
mistaken  for  some  form  of  meningitis.  A  careful  analysis  of  the 
symptoms  and  physical  signs  will,  however,  usually  make  the 
diagnosis  plain.    A  lumbar  puncture  will  settle  it  at  once. 

Prognosis. — Infectious  diarrhea  in  infancy  is  always  a  serious 
disease.    The  prognosis  should  always  be  a  guarded  one.     It  is 


308  TREATMENT 

impossible  to  know  in  the  beginning  what  the  result  is  to  be. 
Death  may  occur  in  three  or  four  days,  but  most  often  takes  place 
during  the  second  week  of  the  disease.  It  may  be  delayed,  how- 
ever, for  several  weeks.  Improvement  usually  begins,  in  the  cases 
which  recover,  at  the  end  of  the  first  or  during  the  second  week. 
It  may  be  delayed  for  several  weeks.  Recovery  is  usually  slow 
and  likely  to  be  interrupted  by  relapses.  In  some  instances  the 
disease  runs  into  a  chronic  form  which  may  last  for  many  weeks. 
Most  of  these  cases  eventually  die,  but  some  recover. 

Symptoms  which  render  the  prognosis  more  serious  are  high 
fever,  the  presence  of  much  blood  in  the  stools  and  the  appearance 
of  symptoms  of  marked  toxic  absorption,  such  as  persistent  vomit- 
ing, marked  restlessness  and  convulsions.  The  presence  of  albumin 
and  other  evidences  of  degeneration  of  the  kidney  in  the  urine  are 
not  of  especially  bad  prognostic  import. 

Treatment. — The  first  thing  to  be  done  in  infectious  diarrhea  is 
to  thoroughly  clean  out  the  intestinal  tract.  The  best  drug  for  this 
purpose  is  castor  oil.  It  works  quickly,  thoroughly  and  causes  less 
irritation  of  the  intestines  than  other  cathartics.  The  dose  should 
not  be  less  than  two  teaspoonfuls  and  may  be  as  much  as  two 
tablespoonfuls.  It  should  be  given  plain.  Castor  oil  should  be 
tried  first,  even  if  the  baby  is  vomiting,  because  it  is  often  retained 
when  food  and  water  are  vomited.  If  it  is  vomited,  calomel  may 
be  given  in  its  place.  The  usual  dose  is  one-tenth  of  a  grain,  com- 
bined with  one  grain  of  bicarbonate  of  soda,  every  half  hour  until 
1  or  13^  grains  have  been  given.  It  is  wise  to  follow  it  with  two 
or  three  teaspoonfuls  of  the  milk  of  magnesia  in  two  or  three  hours 
after  the  last  dose.  The  treatment  should  be  repeated,  if  the 
desired  results  are  not  obtained.  The  lower  bowel  should  also 
be  irrigated  at  once  with  physiological  salt  solution  (approximately 
one  teaspoonful  of  salt  to  a  pint  of  water). 

All  food  should  be  stopped  for  from  twelve  to  twenty-four 
hours.  It  is  not  desirable,  as  a  rule,  to  withhold  food  longer  than 
this.  It  is  necessary,  however,  to  give  water  freely  during  this 
period,  because,  although  a  baby  can  bear  temporary  starvation,  it 
cannot  get  along  without  water.  At  least  as  much  water  should  be 
given  as  the  baby  would  normally  take  of  liquid  in  the  form  of 
food  in  the  given  time.  The  water  may  be  given  either  warm  or 
cool  and  may  be  sweetened  with  saccharin,  if  desired.  There  is  no 
objection  to  giving  it  in  the  form  of  weak  tea  sweetened  with 
saccharin,  if  it  is  taken  better  in  this  way.  It  should  be  given 
through  a  tube,  if  the  baby  will  not  take  it  otherwise. 

The  most  important  element  in  the  treatment  of  infectious 


TREATMENT  309 

diarrhea  is  the  diet.  The  character  of  the  diet  depends  on  the 
variety  of  microorganism  which  is  causing  the  disease.  These 
microorganisms  can  be  divided,  as  far  as  the  determination  of  the 
diet  to  be  used  in  concerned,  into  two  groups; 

1.  The  various  forms  of  the  dysentery  bacillus  and  the  other 
organisms,  except  the  gas  bacillus,  which  cause  the  disease. 

2.  The  gas  bacillus  and  allied  organisms. 

The  other  organisms,  although  of  many  different  varieties,  are 
grouped  with  the  dysentery  bacilli,  because  as  regards  their  growth 
and  the  production  of  toxic  substances  from  protein  and  carbo- 
hydrate media,  they  behave  in  the  same  way. 

The  dysentery  bacillus,  the  colon  bacillus  and  the  streptococcus 
belong  to  the  class  of  facultative  bacteria.  This  class  of  organisms 
can  thrive  upon  either  carbohydrate  or  protein  media.  They 
produce  harmless  products  from  carbohydrates  and  toxic  sub- 
stances from. protein.  They  act  upon  and  use  up  the  carbohydrate 
material  before  they  attack  the  protein,  when  both  are  present  in 
the  medium  in  which  they  are  growing.  The  products  of  the 
breaking  down  of  the  carbohydrate  material  have,  moreover,  when 
produced  in  sufficient  amounts,  an  inhibitory  action  on  the  develop- 
ment of  dysentery  bacilli  and,  to  a  less  extent,  of  streptococci. 

It  is  evident,  therefore,  that  when  infectious  diarrhea  is  caused 
by  bacteria  of  this  type,  the  food  should  be  largely  carbohydrate  in 
character.  In  this  way  the  organisms  are  prevented  from  forming 
toxic  substances  and  their  growth  is,  to  a  certain  extent,  inhibited. 
The  prolonged  withdrawal  of  food  is  also  contraindicated,  because 
the  intestinal  contents  are  then  made  up  entirely  of  the  intestinal 
secretions,  which  are  protein  in  character.  Some  form  of  carbo- 
hydrate should,  therefore,  be  given  after  a  few  hours.  Sugar  is 
preferable  to  starch,  because  it  is  much  more  easily  utilized  by 
bacteria.  Lactose  is  preferable  to  the  dextrin-maltose  preparations, 
because  it  is  more  slowly  broken  down  during  the  processes  of 
digestion.  Being  less  readily  absorbed,  it  thus  provides  a  carbo- 
hydrate medium  in  the  intestine  for  a  longer  time  than  the  dextrin- 
maltose  combinations.  It  is  probable,  moreover,  that  a  larger 
proportion  of  lactic  acid  is  formed  from  milk  sugar  than  from 
the  other  sugars,  and  lactic  acid  has  an  inhibitory  action  on  the 
development  of  the  dysentery  bacillus.  The  lactose  should  be 
given  in  the  form  of  a  5%  or  7%  solution  in  water.  It  is  better  to 
give  it  frequently  in  small  amounts  than  in  larger  amounts  at 
longer  intervals,  because  in  this  way  a  continuous  supply  of  lactose 


310  TREATMENT 

is  brought  to  the  intestines.  The  baby  should  be  given  at  least 
as  much  of  the  sugar  solution  as  it  would  take  of  food  under  normal 
conditions.  Half  as  much  more  is  usually  advisable.  There  is 
little  or  no  danger  of  producing  sugar  indigestion  or  glycosuria,  if 
no  more  than  this  is  given. 

After  twenty-four,  forty-eight  or  seventy-two  hours,  as  the  case 
may  be,  it  is  wise  to  give  the  milk  sugar  in  barley  water.  The 
barley  water  should  contain  from  0.75%  to  1%  of  starch.  The 
starch  provides  more  nourishment  and,  being  still  more  slowly 
broken  up  and  absorbed,  favors  still  further  the  prolonged  con- 
tinuance of  a  carbohydrate  medium  in  the  intestine. 

It  is  necessary  to  add  some  protein  to  the  food  as  soon  as  possible 
in  order  to  neutralize  the  protein  waste  of  the  organism.  It  should 
be  given  as  soon  as  there  is  evidence  of  improvement  of  the  condi- 
tion. Care  must  be  taken  not  to  give  so  much  as  to  neutralize  the 
action  of  the  carbohydrates.  It  is  usually  safe  to  begin  with 
0.50%,  increasing  the  amount  0.25%  at  a  time  as  fast  as  possible 
up  to  about  1.50%.  It  may  be  given  either  in  the  form  of  whey 
protein  or  casein.  If  it  is  added  in  the  form  of  casein,  the  mixture 
should  be  boiled  in  order  to  prevent  the  formation  of  casein  curds. 
No  fat  should  be  given  until  convalescence  is  well  established. 

Irrigations  of  the  colon  with  solutions  of  lactose  or  dextrose, 
while  theoretically  indicated,  are  of  little  practical  value. 

The  microorganisms  which  cause  the  disease  enter  the  intestinal 
wall  and  probably  in  many  instances  reach  the  mesenteric  lymph 
nodes  and  perhaps  the  general  circulation.  The  available  supply 
of  glycogen  is  quickly  used  up  or  greatly  diminished  in  illness, 
especially  when  associated  with  total  or  partial  starvation,  and  the 
conditions  favorable  for  the  development  of  toxic  substances  by 
the  bacteria  which  have  left  the  intestines  are  thus  provided.  The 
introduction  of  dextrose  into  the  circulation  would,  therefore, 
furnish  a  carbohydrate  instead  of  a  protein  medium  for  the  bacteria 
to  grow  in.  The  dextrose  also  provides  an  immediately  utilizable 
supply  of  energy  and  spares  the  body  protein.  Dextrose  infusions 
are,  therefore,  indicated  in  severe  cases  of  infectious  diarrhea  of 
this  type  and  in  cases  which  are  not  yielding  rapidly  to  treatment. 
The  strength  of  the  infusion  should  be  2.5%  of  dextrose  in  normal 
saline  solution.  Kahlbaum's  is  the  only  readily  available  pure 
dextrose.  Three  or  four  ounces  of  the  solution  may  be  given  at  a 
time  and  repeated  every  four  to  six  hours.  The  administration  of 
these  infusions  should  be  checked  by  urinalysis  and  must  cease  if 
sugar  appears  in  the  urine. 

The  gas  bacillus  and  alUed  organisms  grow  rapidly  in  the  in- 


TREATMENT  311 

testinal  tract  when  there  is  an  excess  of  utilizable  carbohydrate  in 
the  bowel  and  at  the  same  time  an  insufficient  number  of  those 
organisms  which  form  lactic  acid  from  carbohydrates  to  produce 
enough  lactic  acid  to  inhibit  their  gorwth,  the  gas  bacillus  being 
sensitive  to  lactic  acid.  The  indications  to  be  followed  in  the  treat- 
ment of  cases  of  infectious  diarrhea  caused  by  the  gas  bacillus  are, 
therefore,  to  cut  down  the  carbohydrates  in  the  diet  and  to  intro- 
duce acid  producing  bacteria  into  the  intestines.  These  indica- 
tions can  be  best  met  by  the  use  of  unheated  buttermilk  or,  better, 
of  mixtures  containing  no  fat,  3%  or  4%  of  milk  sugar  and  from 
1.50%  to  2.50%  of  protein,  ripened  with  lactic  acid  forming  or- 
ganisms. It  is  not  impossible  to  cut  out  the  sugar  entirely,  be- 
cause, if  this  is  done,  the  lactic  acid  forming  organisms  will  have 
nothing  on  which  to  grow.  The  lactic  acid  already  present  in  the 
food  exerts  an  immediately  inhibitory  action  upon  the  gas  bacillus, 
while  the  lactic  acid  forming  organisms  in  it,  by  keeping  up  their 
production  of  lactic  acid,  continue  this  action.  They  also  use  up  the 
available  supply  of  carbohydrate  and  thus  interfere  with  the 
growth  of  the  gas  bacillus.  Lactic  acid  given  by  the  mouth  is  much 
less  effective,  because  it  is  rapidly  broken  down  and  absorbed  and, 
therefore,  does  not  have  a  continuous  action.  Pasteurized  butter- 
milk, in  which  the  lactic  acid  forming  organisms  are  destroyed,  is 
less  valuable  than  raw  buttermilk  for  the  same  reason. 

Cutting  down  the  carbohydrates  in  the  diet  and  increasing  the 
amount  of  protein  in  it  is  sufficient  to  relieve  the  condition  in  mild 
cases.  The  percentage  of  fat  should  also  be  kept  low.  Mixtures 
containing  from  1%  to  1.50%  of  fat  and  from  1.50%  to  3%  of  pro- 
tein, and  with  no  more  milk  sugar  than  is  necessarily  added  in  the 
milk  and  cream  to  give  the  desired  percentages  of  fat  and  protein 
are  suitable  ones.  It  is  well  to  boil  them  in  order  to  prevent  the 
formation  of  casein  curds. 

It  is  evident  that  the  line  of  diet  which  is  suitable  for  one  type  of 
infectious  diarrhea  is  not  only  not  suitable,  but  absolutely  harmful, 
for  the  other,  and  vice  versa.  It  is  extremely  important,  therefore, 
not  to  make  a  mistake  in  the  choice.  It  is  unfortunately  almost 
impossible  to  determine  at  once  what  form  of  microorganism  is  the 
cause  in  the  individual  case.  The  various  methods  to  be  used  to 
get  at  the  organism  at  fault  have  already  been  detailed.  A  point 
which  is  of  some  assistance  in  arriving  at  a  tentative  conclusion 
until  these  measures  have  been  carried  out  is  that  in  a  given  season 
the  vast  majority  of  the  cases  of  infectious  diarrhea  are  due  to  the 
same  organism.  If  the  prevailing  organism  is  known,  the  chances 
are,  therefore,  that  this  organism  is  also  the  cause  in  the  given  case. 


812  TREATMENT 

Another  method  of  determining  the  cause,  a  method  which  is 
most  miscientific  but  nevertheless  often  the  only  practicable  one, 
is  to  give  what  seems  to  be  the  most  rational  diet  and  then  observe 
the  results.  If  the  temperature  begins  to  come  down  and  the  pa- 
tient improves,  it  is  almost  certain  that  the  organism  causing  the 
disease  is  of  the  type  for  which  that  form  of  dietetic  treatment  is 
indicated.  If,  on  the  other  hand,  the  temperature  remains  ele- 
vated or  rises  and  there  is  no  improvement  in  the  other  symptoms, 
it  is  evident  that  the  causative  organism  belongs  to  the  other  type 
and  that  the  diet  must  be  changed. 

Irrigation  of  the  bowels  once  or  twice  in  the  twenty-four  hours  is 
a  useful  procedure.  -The  object  of  the  irrigation  is  simply  to 
cleanse  the  colon.  It  is  impossible  to  use  astringent  solutions 
strong  enough  to  have  any  appreciable  action  upon  the  intestinal 
wall,  even  if  this  was  desirable,  or  antiseptic  solutions  strong 
enough  to  have  any  effect  upon  the  pathogenic  bacteria  without 
running  serious  risk  of  poisoning  the  baby.  The  irrigating  solution 
should,  therefore,  be  some  mild,  unirritating  solution,  such  as 
physiological  salt  solution  or  a  1%  solution  of  boracic  acid.  The 
irrigation  should  be  given  with  a  soft  rubber  catheter,  No.  25 
French,  passed  as  high  as  possible  into  the  bowel,  with  the  patient 
lying  on  the  back  and  the  hips  elevated.  The  fluid  is  then  allowed 
to  run  in  from  a  bag  hung  not  more  than  two  feet  above  the  level 
of  the  patient.  It  should  be  allowed  to  run  in  until  the  abdomen 
is  slightly  distended,  then  allowed  to  run  out,  and  so  on,  until  the 
wash  water  returns  clear.  The  object  of  the  irrigation  being  to 
cleanse  the  colon,  enough  liquid  should  be  used  to  do  this,  whether 
it  is  much  or  little.  Irrigation  should  seldom  be  done  more  than 
twice  in  the  twenty-four  hours.  If  it  depresses  or  disturbs  the 
patient  materially,  it  should  be  given  up,  as  under  these  circum- 
stances it  does  more  harm  than  good. 

In  subacute  or  chronic  cases,  in  which  blood  and  pus  persist  in 
the  stools  after  the  temperature  has  dropped  and  the  evidences 
of  toxemia  have  disappeared,  injections  of  nitrate  of  silver  are 
sometimes  useful  and  seem  to  hasten  the  healing  of  the  bowel. 
They  may  be  used  in  the  acute  stage,  but,  as  a  rule,  do  but  little 
good  at  this  time.  The  colon  should  first  be  irrigated  with  sterile 
water  in  order  to  cleanse  it.  Salt  solution  should  not  be  used,  be 
cause  the  sodium  chloride  forms  with  the  silver  nitrate  an  in- 
soluble silver  salt  which  is  precipitated  and  the  action  of  the  silver 
solution  is  consequently  diminished.  After  the  bowel  has  been 
washed  out,  from  six  to  sixteen  ounces,  according  to  the  age  of  the 
baby,  of  a  2%  or  3%  solution  of  the  nitrate  of  silver  are  allowed  to 


TREATMENT  313 

run  into  the  colon  and  the  tube  then  withdrawn.  No  attempt 
should  be  made  to  have  the  fluid  either  retained  or  expelled.  This 
procedure  seldom  causes  any  marked  discomfort  in  babies.  If  it 
does,  the  silver  solution  may  be  washed  out  with  salt  solution  or  an 
opium  suppository  given.  The  injections  should  be  repeated  every 
day  or  every  other  day.  If  there  is  no  evident  improvement  aft^r 
three  or  four  injections  it  is  useless  to  continue  them.  The  first 
stools  passed  after  an  injection  usually  contain  more  blood  and 
considerable  dirty  gray  material,  consisting  of  slough  from  the 
ulcers,  intestinal  secretions  and  pus,  discolored  by  the  silver  ni- 
trate. In  favorable  cases,  however,  there  is  marked  improvement 
in  the  character  of  the  stools  inside  of  twenty-four  hours. 

The  various  so-called  intestinal  antiseptics  are  of  little  or  no 
value  in  the  treatment  of  infectious  diarrhea.  It  is  impossible  to 
give  them  in  large  enough  doses  to  have  any  effect  on  the  path- 
ogenic bacteria  in  the  intestines  without  poisoning  the  baby.  If 
they  did  have  any  action,  it  would  be  exerted  on  the  antagonistic 
as  well  as  on  the  pathogenic  bacteria.  Moreover,  the  bacterial 
flora  can  be  modified  better  by  regulation  of  the  diet  than  in  any 
other  way.  In  addition,  it  disturbs  the  patient  to  take  them  and 
interferes  with  the  administration  of  food  and  water.  The  salts  of 
bismuth  are  of  little  value  during  the  acute  stage,  whether  or  not 
they  are  combined  with  sulphur.  During  the  chronic  stage  they 
sometimes  seem  to  diminish  peristalsis  and  perhaps  promote  heal- 
ing. When  used,  they  should  be  given  in  doses  of  from  ten  to 
twenty  grains  every  two  hours.  It  is  safer  to  use  the  subcarbonate 
or  the  milk  of  bismuth  than  the  subnitrate,  because  of  the  danger 
of  nitrite  poisoning  when  the  subnitrate  is  used. 

There  is  no  serum  which  is  of  any  value  in  the  treatment  of 
infectious  diarrhea. 

Pain  and  tenesmus  are  often  very  troublesome  symptoms.  In- 
jections of  two  ounces  of  starch  solution  of  the  strength  of  one 
drachm  of  starch  to  one  ounce  of  water,  to  which  are  added  from 
three  to  five  drops  of  laudanum,  will  sometimes  control  the  tenes- 
mus. They  are  usually  expelled,  however,  before  they  have  had 
time  to  do  any  good.  It  is  generally  wiser,  therefore,  to  give  the 
opium  by  mouth,  if  it  is  necessary  to  use  it  at  all.  It  must  be 
remembered  when  giving  opium  that  its  action  is  to  diminish 
peristalsis  and  that  if  the  peristalsis  is  diminished  enough  to  inter- 
fere with  the  free  emptying  of  the  bowels  serious  harm  will  be  done. 
Only  enough  should  be  given  to  allay  the  tenesmus  and  prevent 
the  frequent  stools  due  to  excessive  peristalsis.  The  safest  form  of 
opium  to  use  is  paregoric.    It  may  be  given  in  doses  of  from  five  to 


314  TREATMENT 

twenty  drops.  Dover's  powder,  in  doses  of  from  one-eighth  to  one- 
half  of  a  grain,  may  also  be  used.  It  is  better  to  give  small  doses 
at  short  intervals  than  larger  doses  at  longer  intervals.  The  use  of 
hot  stupes  or  compresses  to  the  abdomen  will,  however,  often 
relieve  the  pain  and  tenesmus  and  render  the  use  of  opium  un- 
necessary. 

In  some  instances  it  is  impossible  to  induce  the  infant  to  take  a 
sufficient  amount  of  water  or,  if  it  does  take  it  or  it  is  given  through 
a  tube,  it  is  vomited.  In  such  cases  physiological  salt  solution 
should  be  given  subcutaneously  to  make  up  the  deficit.  From  four 
to  six  ounces  may  be  given  at  a  time  and  repeated  as  often  as  nec- 
essary. It  is  useless  to  give  a  second  injection,  however,  before 
the  first  one  is  absorbed.  Salt  solution  may  also  be  given  through 
the  bowel  by  seepage.  Considerable  amounts  can  sometimes  be 
introduced  in  this  way,  even  when  the  baby  is  having  many  stools. 
It  may  also  be  given  into  the  longitudinal  sinus  or  intraperitoneally. 

Stimulants  are  often  necessary  in  infectious  diarrhea  in  infancy, 
as  in  other  acute  diseases.  There  are  no  special  rules  to  be  followed 
in  infectious  diarrhea.  Alcohol  is  of  doubtful  value.  Strychnia  is, 
in  general,  the  most  useful,  while  caffeine  and  camphor  are  the 
best  quick  stimulants.  Strychnia  may  be  given  in  doses  of  from 
1/1000  to  1/200  of  a  grain.  The  dose  of  the  citrate  of  caffeine  by 
mouth  for  a  baby  is  from  one-eighth  to  one-half  of  a  grain  and  of 
caffeine-sodium  benzoate  or  salicylate  subcutaneously  about  the 
same.  Camphor  may  be  given  subcutaneously  in  oil  in  doses  of 
one  or  two  grains. 

Special  Symptoms. — Babies  that  are  seriously  ill  with  either 
indigestion  with  fermentation  or  infectious  diarrhea  are  very  likely 
to  show  one  or  more  rather  characteristic  symptoms  or  groups  of 
symptoms.  One  of  these  groups  of  symptoms  almost  invariably 
develops  toward  the  end  in  fatal  cases.    These  symptoms  are: 

a.  Excessive  vomiting. 

b.  Hyperpyrexia. 

c.  Symptoms  of  irritation  of  the  central  nervous  system. 

d.  Prostration  and  collapse. 

It  is  probable  that  these  sjrmptoms  are  chiefly  manifestations  of 
toxemia.  How  much  of  the  intoxication  is  due  to  the  absorption 
of  bacterial  endotoxines  and  extracellular  toxines,  how  much  to  the 
absorption  of  the  products  of  bacterial  fermentation  in  the  intes- 
tinal contents,  and  how  much  to  purely  chemical  disturbances  of 
metabolism,  it  is  impossible  to  state.    It  is  presumable  that  the 


VOMITING  AND  HYPERPYREXIA  315 

loss  of  water  through  the  bowels  also  plays  a  part  in  their  produc- 
tion. 

If,  when  any  of  these  symptoms  appear,  there  is  any  doubt  as  to 
whether  the  bowels  have  been  throughly  emptied,  it  is  advisable 
to  repeat  the  initial  catharsis  and  irrigation.  It  is  also  advisable,  if 
the  condition  of  the  nutrition  warrants  it,  to  withhold  food  for 
about  twelve  hours.  This  must  be  done  only  after  due  deUberation, 
however,  if  the  cause  of  the  infectious  diarrhea  is  any  other  or- 
ganism than  the  gas  bacillus.  In  all  of  these  cases,  unless  the 
babies  are  taking  and  retaining  sufficient  liquid  by  mouth,  it  is 
advisable  to  give  salt  solution  subcutaneously  or  by  seepage. 

Little  can  be  done  for  excessive  vomiting  beyond  the  general 
measures  already  detailed,  except  to  withdraw  all  food  entirely  and 
wash  out  the  stomach  with  a  solution  of  bicarbonate  of  soda  of  the 
strength  of  one  level  teaspoon  ful  to  the  pint  of  water.  In  some 
instances,  small  amounts  of  this  same  solution  of  bicarbonate  of 
soda,  of  one  of  the  aerated  waters  or  of  ginger  ale,  will  be  retained 
when  food  and  water  are  not.  The  vomitus  not  infrequently  con- 
tains brownish  or  reddish  flecks  or  streaks  as  the  result  of  capillary 
hemorrhages  into  the  stomach.  This  sign  is  of  serious,  but  not 
necessarily  of  fatal,  import. 

The  hyperpyrexia  is  best  treated  by  the  .use  of  cold  externally. 
It  is  very  seldom  advisable  to  give  the  coal  tar  products  to  infants 
to  reduce  the  temperature.  Sponge  baths  of  equal  parts  of  alcohol 
and  water,  at  90°  F.,  are  usually  effective.  If  they  are  not,  fan 
baths  may  be  tried.  Fan  baths  are  given  in  the  following  way: 
The  baby  is  stripped  and  wrapped  in  cheesecloth.  This  is  then 
wet  with  water  at  100°  F.  and  the  baby  is  fanned.  The  tempera- 
ture is  reduced  by  the  evaporation  of  the  water.  The  cheesecloth 
is  wet  from  time  to  time  as  the  water  evaporates.  Babies  seldom 
object  to  this  form  of  bath.  If  this  is  ineffectual,  the  cold  pack  at 
from  60°  F.  to  70°  F.  should  be  tried.  Babies  seldom  bear  tub 
baths  well  and  it  is,  as  a  rule,  wiser  not  to  use  them. 

An  ice  bag  may  also  be  applied  to  the  head.  It  must  not  be 
forgotten,  however,  that  a  baby's  skull  is  very  thin  and  that  the 
effect  of  the  cold  is,  therefore,  greater  than  in  the  adult.  This  is 
especially  true  when  the  fontanelle  is  open.  Great  care  must, 
therefore,  be  exercised  in  the  use  of  the  ice  cap  in  infancy. 

Lowering  the  temperature  of  the  liquid  used  in  irrigating  also 
aids  in  reducing  the  fever.  It  may  be  reduced  to  100°  F.  or  95°  F, 
and  in  desperate  cases  to  90°  F. 

The  nervous  symptoms  are  very  varied.  In  some  instances  the 
babies  are  stupid,  comatose  or  relaxed.    In  others  they  show  the 


316  NERVOUS  SYMPTOMS 

typical  picture  of  coma  vigil.  Marked  restlessness  is  a  very  com- 
naon  manifestation.  Twitching  is  not  uncommon  and  convulsions 
not  very  infrequent.  In  many  instances  there  are  marked  signs  of 
meningeal  irritation.-  The  head  may  be  retracted,  the  pupils 
unequal,  the  knee-jerks  exaggerated,  and  so  on.  In  fact,  the 
picture  may  be  almost  exactly  that  of  meningitis,  so  much  so  that  a 
diagnosis  can  only  be  made  positively  by  lumbar  puncture.  The 
results  of  this  procedure  are  also  sometimes  misleading,  because  the 
cerebrospinal  fluid  in  this  condition  sometimes  shows  a  slight 
globulin  test  and  a  moderate  excess  of  mononuclear  cells.  The 
pathological  condition  is  presumably  one  of  meningeal  irritation  or 
serous  meningitis.  The  treatment  of  these  nervous  manifestations 
is  purely  symptomatic.  Bromide  of  soda,  in  doses  of  from  five  to 
ten  grains,  by  mouth,  may  be  given  for  restlessness  and  excite- 
ment. It  may  be  combined  with  one  or  two  grains  of  chloral 
hydrate.  It  is  ordinarily  useless  to  give  drugs  by  enema  in  these 
conditions,  as  they  are  almost  never  retained.  If  the  bromide  and 
chloral  do  not  control  the  symptoms,  morphine  may  be  given  by 
mouth  or  subcutaneously,  in  doses  of  from  1/100  of  a  grain  to  1/32 
of  a  grain.  It  is  always  advisable  in  giving  morphine  to  infants  to 
begin  with  a  very  small  dose  and  then  increase  it,  if  necessary. 
An  ice  bag  on  the  head  sometimes  helps.  When  the  fontanelle  is 
full,  a  lumbar  puncture  will  often  give  rehef .  Convulsions  should 
be  treated  in  the  usual  manner. 

There  is  nothing  especially  characteristic  about  the  manifesta- 
tions of  prostration  and  collapse  in  these  conditions.  They  are  to 
be  treated  in  the  same  way  that  they  are  when  they  occur  in  other 
conditions.  It  is  important  to  remember,  however,  that  all  forms 
of  treatment  weaken  and  exhaust  the  baby.  Irrigations  must  be 
omitted  and  the  baby  disturbed  as  little  as  possible.  It  must  be 
kept  warm  and  protected  in  every  way.  They  are  likely,  however, 
to  be  associated  with  a  certain  amount  of  vasomotor  paralysis  and 
lowering  of  the  blood  pressure.  Alcohol  is,  therefore,  contrain- 
dicated.  Adrenalin  is  of  some  value  under  these  circumstances,  in 
doses  of  from  two  to  ten  minims  of  the  1-1000  solution,  given 
subcutaneously.  Its  action  is  much  greater  when  it  is  given  in- 
travenously. Unfortunately,  intravenous  injection  is  not  an  easy 
matter  in  infancy.  It  has  practically  no  effect  when  given  by  the 
stomach.  Strychnia  is,  in  general,  the  most  useful  of  the  stimu- 
lants, while  caffeine  and  camphor  are  the  best  quick  stimulants. 
Strychnia  may  be  given  in  doses  of  from  1/1000  to  1/200  of  a  grain. 
The  dose  of  the  citrate  of  caffeine  by  mouth  for  a  baby  is  from 
one-eighth  to  one-half  a  grain,  and  of  caffeine-sodium  benzoate  or 


CHOLERA  INFANTUM  317 

salicylate  subcutaneously  about  the  same.    Camphor  may  be  given 
subcutaneously  in  oil  in  doses  of  from  one  to  two  grains. 

CHOLERA  INFANTUM 

There  can  be  no  doubt  as  to  the  existence  of  the  symptom- 
complex  which  is  usually  designated  by  the  name  "cholera  in- 
fantum." It  has  all  the  earmarks  of  an  acute,  specific,  infectious 
disease.  Hence  it  seems  rational  to  classify  it  under  the  head  of 
infectious  diarrhea.  No  specific  microorganism  has,  however,  ever 
been  found  for  the  disease.  In  fact,  it  is  not  certain  that  it  is 
caused  by  any  form  or  forms  of  microorganisms.  It  is  possible 
that  it  is  merely  a  peculiar  manifestation  of  some  unusual  type  of 
intoxication  or  disturbance  of  metabolism.  However  that  may  be, 
the  symptom-complex  is  so  striking  that  it  deserves  description  as  a 
separate  entity.  It  is  a  rare  condition.  It  almost  never  occurs  in 
children  over  two  years  of  age  and  never  except  in  hot  weather. 

Pathology. — The  pathological  changes  are  practically  nil.  All 
the  tissues  are  drained  of  their  liquid.  There  are  no  lesions  of  the 
intestines  beyond  the  evidences  of  a  desquamative  catarrh  or  a 
moderate  hyperemia  of  the  mucous  membrane.  There  may  be 
evidences  of  cerebral  hyperemia  and  occasionally  of  edema,  but 
these  are  usually  wanting.  The  kidneys  show  evidences  of  degen- 
eration, but  no  changes  sufficient  to  account  for  the  symptoms. 
The  other  parenchymatous  organs  also  show  degenerative  changes. 

Symptomatology. — ^The  sjmaptoms  are  due  primarily  to  the 
action  of  some  toxic  substance  upon  the  heart  and  nervous  system, 
the  vasomotor  nerves  of  the  intestines  being  especially  affected, 
and  secondarily,  to  the  draining  of  fluid  from  the  various  organs. 

The  onset  of  the  disease  is  usually  preceded  by  some  of  the 
symptoms  of  indigestion,  but  it  may  develop  in  an  infant  ap- 
parently perfectly  healthy.  The  development  of  the  symptoms 
when  they  once  appear  is,  however,  extremely  rapid,  so  rapid,  in 
fact,  that  a  baby  may  be  moribund  in  five  or  six  hours.  The  first 
symptoms  are  ordinarily  restlessness  or  prostration  with  more  or 
less  abdominal  discomfort  and  a  rising  temperature.  Vomiting 
begins  in  a  few  hours  and  is  accompanied  or  quickly  followed  by 
profuse  diarrhea.  The  first  vomitus  and  stools  are  made  up  of 
whatever  happens  to  be  in  the  stomach  and  intestines  at  the  time 
of  the  onset.  After  that  the  vomitus  and  stools  are  composed  al- 
most entirely  of  serum.  The  vomitus  is  often  blood  stained.  The 
stools  are  large,  watery,  almost  colorless  and  without  odor.  The 
reaction  is  usually  acid  in  the  beginning,  but  quickly  becomes 
neutral  and  then   alkaline.     Microscopically  they  show  large 


318  CHOLERA  INFANTUM 

numbers  of  epithelial  cells,  a  few  leucocytes  and  very  many  bacte- 
ria. There  is  sometimes  considerable  tenesmus,  but  in  most  in- 
stances the  sphincters  are  relaxed  and  the  fluid  simply  runs  out  of 
the  bowel  every  few  minutes.  There  is  no  tenderness  in  the 
abdomen  and  no  spasm  of  the  abdominal  muscles.  The  abdomen 
is  usually  sunken.    The  tongue  is  dry  and  red. 

There  is  very  rapid  emaciation  as  the  result  of  the  loss  of  fluid 
from  the  tissues.  The  face  appears  pinched,  the  eyes  sunken,  the 
skin  dry  and  the  fontanelle  depressed.  Thirst  is  a  very  marked 
and  urgent  symptom.  The  secretion  of  urine  is  much  diminished. 
It  is  concentrated  and  highly  acid.  It  usually  contains  albumin 
and  sometimes  casts  and  blood. 

On  account  of  the  accumulation  of  blood  in  the  abdominal 
organs  as  the  result  of  the  vasomotor  paralysis  of  the  abdominal 
vessels  and  the  consequent  interference  with  the  peripheral  circu- 
lation, the  extremities  become  cold  and  the  skin  pale  and  even 
cyanotic.  The  surface  temperature  is  usually  low,  but  the  rectal 
temperature  is  high,  ranging  from  103°  F.  to  104°  F.  In  fatal  cases 
it  may  reach  as  high  as  106°  F.  or  even  108°  F. 

The  pulse  is  rapid  from  the  beginning  and  soon  becomes  very 
feeble  and  irregular.  The  respiration  is  usually  rapid  and  irreg- 
ular, but  at  times  slow  or  sighing.  It  may  be  of  the  Cheyne- 
Stokes  or  Biot  types. 

The  infant  is  usually  restless  at  first  and  whimpers  almost  con- 
stantly. After  a  time  it  becomes  listless  and  stuporous  or  symp- 
toms of  cerebral  irritation  develop.  The  head  is  retracted,  the 
extremities  are  rigid  and  twitching  and  convulsions  appear. 

Prognosis. — The  prognosis  is  a  very  grave  one.  It  is  very 
seldom  that  a  baby  recovers  from  this  disease.  Death  usually 
takes  place  during  the  first  forty-eight  hours  after  the  onset.  The 
disease  seems  to  be  self-limited,  however,  and  if  the  baby  survives 
for  two  or  three  days,  it  usually  recovers.  Recovery  is  ordinarily 
surprisingly  rapid  when  the  severity  of  the  illness  is  taken  into 
consideration.  On  the  other  hand,  the  acute  S3Tiiptoms  may  abate 
and  be  replaced  by  those  of  various  types  of  indigestion.  Sclerema 
sometimes  develops  under  these  conditions.  The  babies  may  even 
then  recover,  but  ordinarily  die  after  a  period  of  malnutrition. 

Treatment. — In  such  a  rapid  and  fatal  disease  it  is  evident  that 
treatment,  to  be  of  any  avail,  must  be  immediate  and  vigorous.  It 
is  probable  that  there  is  a  vasomotor  paralysis  of  the  gastrointes- 
tinal vessels.  Hence  food  and  drugs  introduced  into  the  alimentary 
canal  cannot  possibly  be  absorbed.  They  can  do  no  good  and 
undoubtedly  may  do  harm. 


CHOLERA  INFANTUM  319 

The  main  indications  for  treatment  are:  1,  to  empty  the  stomach 
and  bowels  of  their  toxic  contents;  2,  to  supply  fluid  to  the  tissues 
which  are  being  so  seriously  drained;  3,  to  restore  the  surface 
circulation;  4,  to  reduce  the  temperature;  5,  to  keep  the  patient 
aUve  until  the  disease  has  run  its  course. 

Purgatives  act  too  slowly  to  be  of  much  use  in  this  disease,  and 
the  chief  reUance  must  be  placed  on  stomach  washing  and  intes- 
tinal irrigation.  They  are  of  use  in  the  beginning,  but  do  not  do 
good  after  the  first  few  hours.  It  is  useless  to  expect  to  supply 
fluids  by  the  mouth.  They  are  almost  invariably  vomited.  Cold, 
sterile  water,  in  small  amoimts,  may  be  tried,  however.  The  in- 
jection of  physiological  salt  solution  into  the  cellular  tissue  is 
usually  the  best  method  of  introducing  fluid  into  the  system. 
It  should  be  given  freely  in  doses  of  from  four  to  eight  ounces  at  a 
time  and  repeated  almost  as  soon  as  it  is  absorbed.  This  not  only 
suppHes  fluid  to  the  tissues,  but  assists  in  eliminating  the  toxic 
substances  from  the  blood  and  in  restoring  the  surface  circulation. 
If  a  sufl&cient  amount  cannot  be  given  subcutaneously  it  should 
be  given  into  the  longitudinal  sinus  or  intraperitoneally. 

Irrigations  of  cold  water  tend  to  restore  the  surface  circulation 
and  also  to  reduce  the  temperature.  The  best  methods  for  re- 
storing the  surface  circulation  are  rubbing,  mustard  baths  and  the 
warm  pack.  These  procedures,  however,  are  not  those  best  fitted 
for  the  reduction  of  temperature.  For  this  purpose  cold,  in  the 
form  of  sponging,  fan  baths  or  packs,  must  be  used.  In  the  treat- 
ment of  individual  patients  it  is  often  necessary  to  determine 
whether  it  is  the  internal  congestion  or  the  high  temperature  which 
is  doing  the  more  harm,  and  then  to  treat  the  more  serious  condi- 
tion.   The  reUef  of  one,  however,  often  aids  the  other  also. 

As  food  cannot  be  given,  the  patient  must  evidently  be  kept  alive 
by  stimulation.  As  drugs  given  by  the  mouth  are  not  absorbed, 
this  stimulation  must  be  given  subcutaneously.  The  usual  stim- 
ulants, strychnia,  caffeine  and  camphor,  are  to  be  employed. 
Strychnia  may  be  given  in  doses  of  from  1/1000  to  1/200  of  a  grain, 
subcutaneously.  The  dose  of  caffeine-sodium  benzoate  or  sal- 
icylate is  from  one-eighth  to  one-half  of  a  grain  and  that  of  cam- 
phor, one  or  two  grains.  The  camphor  should  be  given  in  oil. 
Atropine  is  especially  useful  in  these  cases.  It  is  possible  that  it 
has  some  special  action  antagonistic  to  that  of  the  toxic  products 
of  the  disease.  It  is  to  be  used  in  doses  of  from  1/500  to  1/800  of  a 
grain,  repeated  every  two  or  three  hours,  as  necessary.  Morphia  is 
indicated  when  the  diarrhea  and  vomiting  are  extreme  or  when  the 
nervous  manifestations  are  very  marked.     Doses  of  1/100  of  a 


320  CHOLERA  INFANTUM 

grain  are  usually  sufficient.  They  should  be  given  subcutaneously. 
Care  must  be  taken  not  to  give  too  much  or  to  continue  it  too  long. 
In  case  improvement  begins,  stimulants  and  water  may  be  given 
by  the  mouth,  and  soon  after  this,  small  amounts  of  food.  The 
best  food  to  give  first  in  these  cases  is  diluted  human  milk.  It  is 
wise  to  begin  with  one  part  of  milk  and  two  or  three  parts  of 
water,  giving  from  one-half  to  one  ounce  at  a  feeding.  If  this  is 
tolerated,  the  strength  and  the  amount  at  a  feeding  should  be 
increased  as  rapidly  as  is  possible.  There  are  no  very  definite 
indications  as  to  what  combination  of  the  food  elements  should  be 
most  suitable,  when  human  milk  cannot  be  obtained.  The  only 
thing  that  is  certain  is  that  the  food  must  be  a  very  dilute  one. 
Whey  is  as  likely  to  agree  as  anything.  If  this  is  tolerated,  a  mix- 
ture containing  0.25%  of  fat,  5%  of  milk  sugar,  0.75%  of  whey 
protein  and  0.25%  of  casein  may  be  given  next.  If  this  agrees,  the 
percentages  of  fat  and  casein  should  be  gradually  increased.  If 
the  whey  does  not  agree  with  the  baby,  a  mixture  containing  no 
fat,  2%  of  milk  sugar,  0.75%  of  protein  and  0.75%  of  starch  should 
be  tried.  It  is  better  to  boil  this  mixture  in  order  to  prevent  the 
formation  of  large,  casein  curds.  If  this  mixture  is  tolerated,  the 
percentages  of  milk  sugar  and  casein  should  be  increased  and  fat 
added  cautiously. 


CHAPTER  XXVI 

CONSTIPATION 

Constipation  is  not  a  disease.  It  is  a  condition  in  which  the 
number  of  stools  is  less  or  the  consistency  of  the  stools  is  greater 
than  is  normal  for  the  individual  at  the  given  time. 

CONSTIPATION   IN  THE  NEW-BOIiN 

Constipation  in  the  new-bom  must  not  be  confused  with  those 
conditions  in  which  the  absence  of  stools  is  due  to  congenital 
malformations  of  the  intestine,  such  as  imperforate  rectum  and 
atresia  of  the  intestine,  which  mechanically  prevent  the  passage  of 
feces.  It  is  ordinarily  due  at  this  time  to  an  insufficient  intake  of 
food,  as  the  result  of  delay  in  the  secretion  of  the  breast-milk.  In 
other  instances,  in  which  the  supply  of  breast-milk  or  of  artificial 
food  is  sufficient,  the  difficulty  seems  to  be  sluggishness  of  the 
intestinal  peristalsis,  apparently  from  lack  of  use,  or  an  innate 
feebleness  of  the  intestinal  musculature. 

CONSTIPATION  IN   INFANCY 

Etiology. — The  etiology  of  constipation  in  infancy  is  a  very 
varied  one  and  several  factors  are  often  active  in  the  same  case. 
The  causes  of  constipation  at  this  age  can  be  divided  into  several 
classes,  each  of  which  can  be  further  subdivided.  These  classes  are 
so  different  that  they  must  be  considered  separately. 

General  Causes. — These  causes,  which  should,  perhaps,  be  called 
unclassified,  are  very  different  in  their  nature  and  in  their  action. 
They  should  always  be  thought  of,  however,  in  attempting  to 
determine  the  cause  of  constipation.  The  first  of  these  causes  is 
heredity.  The  large  number  of  instances  in  which  constipation  is 
present  in  both  parents  and  infants  makes  it  almost  certain  that 
heredity  plays  a  part  in  the  etiology  of  constipation  in  infancy.  It 
is  probable,  however,  that  this  part  is  a  relatively  minor  one  and 
that  in  most  instances  the  presence  of  constipation  in  one  or  both 
of  the  parents  and  their  infant  is  simply  a  coincidence. 

Insufficiency  of  the  thyroid  gland  is  another  cause  of  constipa- 
tion in  infancy  which  should  always  be  borne  in  mind.    It  would,  of 

321 


322  CONSTIPATION 

course,  not  be  missed  in  well-marked  cases  of  cretinism,  but  is 
easily  overlooked  when  the  characteristic  signs  of  thyroid  insuffi- 
ciency are  slight  or  absent. 

An  insufficient  secretion  of  the  intestinal  glands  or  of  the  liver  is 
presumably  at  the  bottom  of  certain  cases  of  constipation  in  in- 
fancy. It  is  very  difficult,  however,  to  recognize  a  deficiency  in  the 
secretion  of  these  organs  and  to  distinguish  constipation  from  this 
cause  from  that  due  to  minor  errors  in  diet. 

Constipation  is  sometimes  the  result  of  the  administration  of 
opium,  usually  in  the  form  of  paregoric  or  "soothing  syrup." 
This  cause  should  never  be  forgotten  in  those  instances  in  which  no 
other  evident  cause  can  be  determined.  It  must  always  be  remem- 
bered in  this  connection,  moreover,  that  the  parents  may  not  be 
aware  that  the  baby  is  getting  opium,  because  the  drug  may  be 
given  by  a  nurse  or  nursery  maid  without  their  knowledge.  Con- 
stipation in  a  baby,  otherwise  apparently  well,  which  is  very  quiet 
and  which  sleeps  unusually  well,  should  always  suggest  opium  as  its 
cause. 

Mechanical. — The  large  intestine  is  relatively  longer  in  compar- 
ison to  the  small  intestine  in  infancy  than  in  later  life  and  its 
mesentery  proportionately  longer.  The  sigmoid  flexure  makes  up  a 
relatively  larger  portion  of  the  colon  than  later  in  life  and  its 
mesentery  is  comparatively  long.  These  anatomical  conditions 
render  possible  the  production  of  bends  and  kinks  of  the  colon 
which,  while  they  do  not  obstruct  the  lumen  of  the  gut  entirely, 
hinder  the  passage  of  the  intestinal  contents  through  it  and  thus 
mechanically  cause  constipation.  A  Jackson's  membrane  or  some 
other  slight  malformation  in  the  vicinity  of  the  cecum  may  also 
mechanically  interfere  with  the  free  passage  of  the  intestinal  con- 
tents. So  also  may  peritoneal  adhesions,  resulting  from  inflamma- 
tory processes  in  the  past,  whether  before  or  after  birth.  Still 
another  mechanical  cause  of  constipation  in  infancy  is  congenital 
dilatation  of  the  colon,  or  Hirschsprung's  disease.  In  this  conditon 
constipation  often  alternates  with  diarrhea. 

Tumors,  most  often  in  the  pelvis,  may  also  sometimes  be  the 
cause  of  constipation  in  infancy.  In  rare  instances  vesical  calculi 
may  be  large  enough  to  mechanically  interfere  with  the  passage  of 
feces. 

Spasmodic. — Fissure  of  the  anus  may,  on  account  of  the  pain 
which  it  causes  during  defecation,  result  in  obstinate  constipation. 
The  pain  attendant  on  a  movement  of  the  bowels  not  only  makes 
the  baby  put  off  a  movement  as  long  as  possible  but  also  causes 
spasmodic  contraction  of  the  anal  sphincter.     Hemorrhoids,  al- 


CONSTIPATION  323 

though  rare  in  infancy,  may  cause  constipation  in  the  same  way. 
Large,  hard  stools  may  also  cause  spasmodic  constipation  on  ac- 
count of  the  pain  attendant  on  their  passage.  This  form  of  con- 
stipation is,  for  this  reason,  often  a  complication  of  other  types. 
It  may  persist  for  a  long  time  after  the  cause  has  been  removed, 
the  baby  being  afraid  to  have  a  movement  because  of  its  memory 
of  the  pain  associated  with  it  in  the  past.  In  rare  instances  a  tonic 
spasm  of  the  sphincter  is  the  cause  of  the  constipation.  The 
etiology  of  the  spasm  in  these  cases  is  obscure. 

Dietetic. — Abnormalities  in  the  food,  either  in  its  quantity  or 
quality,  make  up  one  of  the  two  most  common  of  the  classes  of  the 
causes  of  constipation  in  infancy. 

The  most  common  abnormalities  in  breast-milk  which  result 
in  constipation  are  an  insufficient  amount  of  milk,  a  dilute  milk  and 
a  milk  low  in  fat.  The  cause  of  the  constipation  is  the  same  in  all. 
The  solids  of  the  milk  are  so  completely  absorbed  that  there  is  not 
sufficient  residue  left  to  form  the  normal  amount  of  feces.  In  rare 
instances  a  high  percentage  of  fat  in  breast-milk  is  the  cause  of 
constipation.  The  explanation  is  the  same  as  when  there  is  a  high 
percentage  of  fat  in  artificial  foods. 

Constipation  follows  when  an  insufficient  amount  of  an  artificial 
food  is  given  or  when  the  food  is  too  weak,  because  the  solids  of  the 
milk  are  so  completely  absorbed  that  there  is  not  sufficient  residue 
left  to  form  the  normal  amount  of  feces.  An  artificial  food  which  is 
low  in  fat,  although  it  contains  a  sufficient  amount  of  carbohy- 
drates and  protein,  is  also  often  accompanied  by  constipation. 
The  cause  of  the  constipation  in  this  instance  is  the  fact  that 
the  carbohydrates  and  protein  are  almost  entirely  absorbed  and 
therefore  make  but  a  small  amount  of  fecal  matter,  while  a  con- 
siderable proportion  of  the  feces  is  derived  from  the  fat  in  the  food. 
A  more  common  cause  of  constipation  in  the  artificially-fed  is  an 
excess  of  fat  in  the  food.  In  these  instances  the  fat  combines  with 
the  earthy  alkalis  to  form  the  so-called  "soap-stools."  These 
stools  vary  in  color  from  light-yellow  to  gray.  They  are  sometimes 
large  and  hard.  In  other  instances  they  are  dry  and  crumbly, 
resembling,  in  typical  cases,  the  stools  of  a  dog  which  has  been 
eating  bones.  An  excess  of  starch  in  the  food  may  also  cause  con- 
stipation. When  the  constipation  is  due  to  this  cause,  the  stools 
are  large,  brownish,  dry  and  brittle. 

The  heating  of  milk  unquestionably  predisposes  to  constipation, 
but  only  to  a  slight  extent.  It  is  a  far  less  common  cause  of  consti- 
pation than  is  ordinarily  supposed.  The  boiling,  or  sterilization,  of 
milk  has  more  influence  than  does  the  pasteurization  of  milk,  in. 


324  CONSTIPATION 

fact,  the  pasteurization  of  milk  at  temperatures  below  167°  F.  has 
almost  no  appreciable  influence. 

One  of  the  most  common  causes  of  constipation  during  the 
second  year  is  the  abuse  of  milk.  A  baby  of  this  age  should  seldom 
take  over  thirty-two,  or  at  most  forty,  ounces  of  milk  in  twenty- 
four  hours.  Constipation  is  very  likely  to  result  if  more  is  given. 
Other  causes  of  constipation  at  this  time  are  an  insufficient  amount 
of  cereal,  orange  juice  and  cooked  fruit. 

Atonic. — Muscular  weakness  is  the  other  of  the  two  most  com- 
mon causes  of  constipation  in  infancy.  The  intestinal  muscles  are 
always  involved,  while  the  abdominal  muscles  are  not  infrequently 
weakened  at  the  same  time.  One  of  the  most  common  causes  of 
weakness  of  the  intestinal  musculature  is  prolonged  indigestion, 
especially  if  associated  with  fermentation.  Rickets  is  very  fre- 
quently associated  with  atonic  constipation.  General  malnutri- 
tion, anaemia  and  wasting  diseases  are  other  common  causes  of 
weakness  of  the  intestinal  muscles. 

Another  cause  of  muscular  weakness  is  lack  of  exercise.  Many 
babies  are  kept  too  quiet  and  not  allowed  to  use  their  muscles 
sufficiently  to  keep  up  their  tone.  In  other  instances  the  constipa- 
tion is  due  to  the  facts  that  the  babies  have  not  been  trained  to  have 
a  movement  of  the  bowels  at  a  regular  time  and  have  not  been 
taught  to  use  their  muscles  in  defecation.  It  must  be  remembered 
in  this  connection  that  constipation  in  very  young  babies  may  be 
due  simply  to  the  lack  of  voluntary  effort  on  their  part  to  empty 
the  rectum.  In  such  instances  there  are  no  general  symptoms  of 
constipation  and  the  bowels  move  immediately  if  the  rectum  is 
stimulated  in  some  way,  as  by  the  introduction  of  a  suppository. 

A  still  further  cause  of  what  amounts  to  atonic  constipation  is 
the  continued  use  of  laxative  drugs.  These  get  the  intestines  into 
such  bad  habits  that  they  do  not  respond  to  the  normal  stimulus. 

Symptoms. — It  is  very  difficult  to  describe  the  symptoms  of 
constipation  in  infancy.  Constipated  babies  are  often  irritable  and 
sleepless.  They  frequently  show  evidences  of  general  discomfort. 
Their  tongues  are  coated,  their  breath  is  foul  and  they  suffer  from 
flatulence  and  colic.  All  of  these  symptoms  are,  however,  present 
in  other  conditions,  especially  in  those  which  are  not  infrequently 
the  cause  of  constipation.  It  is  very  difficult,  therefore,  in  many 
instances,  to  determine  what  symptoms  are  due  to  the  constipation 
and  what  to  the  primary  condition.  Pain  during  defecation  is  al- 
most invariably  present  in  the  spasmodic  form.  If  the  constipa- 
tion is  due  to  trouble  low  down  in  the  bowel,  there  are  usually  no 
general  symptoms  associated  with  it. 


TREATMENT  OF  CONSTIPATION  325 

Treatment. — The  first  element  in  the  treatment  of  constipation 
in  infancy  is  to  establish  the  etiology,  that  is,  to  discover  the 
cause  of  the  constipation.  This  demands,  in  most  instances,  a  very 
careful  study  of  the  diet  and  habits  of  the  infant.  Every  detail  has 
to  be  gone  into.  It  also  involves  a  careful  physical  examination 
including,  in  most  instances,  a  rectal  examination.  The  problem 
can  often  only  be  solved  by  the  aid  of  Roentgenograms  taken  after 
bismuth  meals  or  bismuth  enemata.  Abnormalities  in  the  intestine 
interfering  with  the  passage  of  the  intestinal  contents  can  often  be 
discovered  only  in  this  way.  A  lack  of  general  symptoms  in  con- 
nection with  the  constipation  suggests  that  the  trouble  is  in  the 
rectum.  If  the  introduction  of  a  suppository  is  immediately  fol- 
lowed by  the  passage  of  a  normal  stool,  the  rectum  is  certainly  at 
fault.  The  general  symptoms  are  most  marked  when  the  con- 
stipation is  due  to  disturbance  of  the  digestion  in  the  small  intes- 
tine. 

After  the  cause  is  discovered,  the  treatment  must  be  directed  to 
its  removal.  Certain  causes,  such  as  heredity,  cannot,  of  course, 
be  altered.  Others,  such  as  cretinism  and  the  abuse  of  drugs,  can 
be  easily  and  quickly  remedied.  Time  and  the  growth  of  the  parts 
can  alone  remedy  some  of  the  mechanical  conditions,  such  as  the 
long  infantile  colon  and  sigmoid  flexure.  The  other  mechanical 
conditions  demand  operative  interference. 

When  the  constipation  is  due  to  the  pain  caused  by  the  passage 
of  large,  hard  stools,  measures  should  be  taken  to  diminish  the 
size  of  these  stools  and  to  make  them  softer  by  regulation  of  the 
diet  and,  if  necessary,  by  the  temporary  use  of  mild  laxatives. 
When  the  pain  is  due  to  hemorrhoids,  they  should  be  removed. 
Fissure  of  the  anus  can  usually  be  quickly  cured  by  keeping  the 
stools  soft  and  by  the  application  of  boracic  acid  ointment.  The 
application  of  the  nitrate  of  silver  stick  will  help  in  some  cases. 
Stretching  of  the  sphincter  is  almost  never  necessary  in  infancy. 

The  treatment  of  constipation  due  to  errors  in  the  diet  is  self- 
evident.  When  the  dietetic  errors  are  removed  the  constipation 
will  cease.  These  errors  can  be  determined  in  many  instances, 
however,  only  by  the  most  careful  study  of  the  diet  and  by  the 
microscopic  examination  of  the  stools. 

The  chief  element  in  the  treatment  of  the  atonic  form  of  con- 
stipation is  the  relief  of  the  causative  condition,  whether  it  be 
rickets,  malnutrition  or  anaemia.  Another  important  element  in 
these  cases  is  the  training  of  the  baby  to  have  a  movement  at  a 
regular  time  and  to  use  its  abdominal  muscles.  If  the  condition  is 
due  to  laxative  drugs,  they  must  be  stopped. 


326  TREATMENT  OF  CONSTIPATION 

In  most  instances  it  is  necessary  to  relieve  the  symptom,  con- 
stipation, while  the  cause  is  being  removed.  The  measures  to  be 
taken  to  accomplish  this  depend  to  a  certain  extent  on  the  type  of 
constipation  present.  When  the  constipation  is  due  to  muscular 
weakness,  massage  of  the  abdomen  twice  a  day  for  from  five  to  ten 
minutes  is  often  of  considerable  assistance.  It  is  of  less  value  in 
the  other  types.  Foods  which  stimulate  the  intestinal  peristalsis 
are  also  of  especial  value  in  this  form.  Orange  juice  or  prune  juice, 
in  doses  of  from  one  to  four  tablespoonfuls  daily,  may  be  given  dur- 
ing the  first  year  and  baked  apples  and  prune  pulp  during  the 
second  year.  It  is  also  allowable  in  some  cases  to  give  a  few  tea- 
spoonfuls  of  strained  peas,  string  beans  or  spinach,  or  asparagus 
tips,  daily,  during  the  last  quarter  of  the  second  year.  Great 
care  must  be  taken,  however,  not  to  disturb  the  digestion  by  giving 
an  excessive  amount  of  fruit  and  vegetables  and  thus  to  increase  the 
constipation  or  to  set  up  a  diarrhea.  It  is  rarely  advisable  to  give 
bran,  whether  in  the  form  of  crackers,  cookies,  or  rolls,  to  babies, 
although  bran  crackers  can  sometimes  be  used  with  advantage 
toward  the  end  of  the  second  year. 

If  the  stools  are  hard  and  dry,  water,  best  given  between  the 
feedings,  will  often  be  helpful.  Finely  divided  agar  agar,  in  doses 
of  from  one  to  three  teaspoonfuls  daily,  will  often  keep  the  feces 
moist  and  also  increase  their  bulk.  It  should  be  mixed  or  cooked 
with  the  cereals  or  given  in  broth.  Coarse  foods  are  more  likely  to 
do  harm  than  good  in  this  form. 

The  addition  of  oatmeal  water  or  jelly  to  the  food  of  a  baby  in 
the  latter  half  of  the  first  year,  or  the  substitution  of  one  of  these 
for  barley  water,  will  sometimes  aid  in  relaxing  the  bowels.  In 
other  instances,  however,  oatmeal  has  a  constipating  effect  and 
barley  water  acts  as  a  laxative.  The  substitution  of  one  of  the 
dextrins  and  maltose  mixtures  for  milk  or  cane  sugar  sometimes 
relieves  constipation  in  young  babies.  The  greater  the  proportion 
of  maltose,  the  greater,  in  general,  is  the  laxative  action. 

If  these  measures  prove  ineffectual,  it  is  necessary  to  move  the 
bowels  by  the  administration  of  drugs  by  the  mouth  or  by  the 
stimulation  of  the  intestine  from  below.  WTien  the  cause  of  the 
constipation  is  in  the  rectum,  stimulation  from  below  is  plainly 
indicated.  When  the  seat  of  the  trouble  is  higher  up  or  is  a  more 
general  one,  it  is  often  very  difficult  to  decide  which  method  to 
adopt.  A  good  general  rule  is  not  to  use  the  same  method  con- 
tinuously. There  is  less  danger  of  establishing  bad  habits,  if  the 
methods  are  varied. 

There  is  more  danger  of  making  a  baby  dependent  on  stimula- 


TRExlTMENT  OF  CONSTIPATION  327 

tion  of  the  rectum  to  produce  a  movement  than  of  making  it 
dependent  on  drugs.  This  is  especially  true  of  suppositories.  It  is 
very  easy  to  educate  a  baby  to  think  that  it  cannot  have  a  move- 
ment of  the  bowels  unless  it  is  reminded  of  it  by  the  introduction  of 
a  suppository.  Great  care  must  be  exercised  for  this  reason  not  to 
establish  a  bad  habit  in  attempting  to  train  a  baby  to  have  a 
movement  at  a  regular  time  or  on  its  chair.  The  simplest  and 
least  irritating  type  of  suppository  is  a  roll  of  paper  dipped  in 
sweet  oil.  Gluten  suppositories  are  less  irritating  than  glycerin 
suppositories.    The  soap-stick  stands  midway  between  them. 

The  best  and  simplest  form  of  enema  is  that  composed  of  soap 
and  water.  No  more  should  be  given  than  is  sufficient  to  produce 
the  desired  result.  From  two  to  four  ounces  is  usually  enough; 
more  may  be  given  if  necessary.  It  is  best  given  with  a  soft  rubber 
ear-syringe.  A  fountain-syringe  may  be  used,  if  desired.  If  the 
stools  are  hard  and  dry,  an  enema  of  from  one-half  ounce  to  one 
ounce  of  sweet  oil,  given  to  be  retained,  and  followed  later  by  a 
suds  enema,  if  necessary,  is  often  very  useful.  Glycerin  enemas  are 
inadvisable  in  the  treatment  of  constipation  in  infants. 

The  simplest  laxative  for  a  baby  is  milk  of  magnesia.  One 
teaspoonful  a  day  is  usually  sufficient,  but  more  may  be  given,  if 
necessary.  It  is  best  to  give  it  all  at  one  dose,  preferably  at  the 
last  feeding  at  night.  Babies  take  it  without  question,  if  it  is 
mixed  with  their  milk.  Most  babies  are  not  disturbed  by  it.  In  a 
few  it  causes  considerable  pain  and  discomfort  and,  therefore,  has 
to  be  omitted.    Babies  very  seldom  become  dependent  upon  it. 

If  milk  of  magnesia  is  not  well  borne,  phosphate  of  soda  in  doses 
of  from  ten  to  sixty  grains  may  be  substituted  for  it.  This  is  also 
best  given  in  the  milk. 

During  the  latter  part  of  the  second  year,  phenolphthalein,  in 
doses  of  from  one  to  three  grains  is  often  useful.  Cascara  sagrada 
in  doses  of  from  one-half  to  one  grain,  or  of  from  five  to  thirty  drops 
of  one  of  the  liquid  preparations,  may  also  be  used. 

Purgative  drugs,  such  as  castor  oil  and  calomel,  and  to  a  less 
extent  senna,  should  not  be  used  continuously  in  the  treatment  of 
constipation.  They  are  too  powerful  and  have  a  secondary  con- 
stipating action.  Olive  oil  is  useful  in  some  cases.  It  must  never 
be  forgotten,  however,  that  oUve  oil  is  a  fat  and  that  in  those 
cases  in  which  the  constipation  is  due  to  an  excess  of  fat  in  the 
food  it  will  certainly  exaggerate  the  condition.  There  is  also 
danger,  moreover,  of  disturbing  the  digestion  with  it. 


SECTION  V 
DISEASES  OF  NUTRITION 

CHAPTER  XXVII 

RICKETS  , 

Rickets  is  a  constitutional  disease  which  is  ahnost  certainly  due 
to  a  disturbance  of  nutrition.  All  the  organs  and  tissues  of  the 
body  are  affected,  but  the  chief  lesions  are  in  the  bones.  These 
lesions  are  pathognomonic.  Their  chief  characteristic  is  a  local  or 
general  disturbance  of  the  normal  processes  of  ossification.  Rick- 
ets is  most  common  between  the  sixth  and  eighteenth  months.  It 
seldom  occurs  earlier  and  very  rarely  begins  after  the  third  year. 
It  develops,  therefore,  at  a  time  when  the  bones  are  in  process  of 
rapid  development. 

Pathological  Anatomy. — The  bones  grow  in  length  through  the 
formation  of  bone  tissue  in  the  cartilage  between  the  epiphysis  and 
diaphysis.  They  grow  in  thickness  as  the  result  of  the  growth  of 
bone  from  the  inner  layers  of  the  periosteum.  As  the  bone  in- 
creases in  circumference,  the  meduUaiy  canal  is  enlarged  propor- 
tionately by  the  absorption  of  the  inner  layer  of  bone.  Under 
normal  conditions  these  processes  progress  in  regular  order  and  in 
clearly  defined  Hues.  In  rickets  there  is  an  overgrowth  of  the 
cartilaginous  layer  between  the  epiphysis  and  diaphysis  both  in 
width  and  thickness  and  it  is  markedly  hyperemic.  In  this  area 
the  zone  of  proliferation  is  much  enlarged  and  the  cells  are  ar- 
ranged irregularly  instead  of  symmetrically,  as  in  normal  condi- 
tions. The  deposition  of  Ume  salts  and  the  amount  of  calcifica- 
tion is,  nevertheless,  much  less  than  under  normal  conditions.  The 
epiphyseal  centers  of  ossification  are  larger,  softer  and  more 
vascular  than  normal.  There  is  a  similar  disturbance  in  the  sub- 
periosteal formation  of  the  shaft.  The  outer  layers  of  the  shaft 
are  thickened,  but  soft.  The  meduUa  of  the  bone  is  more  hyperemic 
than  normal  and  the  inner  layers  of  the  bone  also  become  softened 
through  lack  of  lime  salts. 

The  visible  results  of  these  abnormaUties  in  the  growth  of  the 

329 


330  RICKETS 

bones  are  enlargement  of  the  bones  at  the  epiphyseal  lines  and  at 
the  centers  of  ossification  and  unnatural  flexibility  of  the  bones. 
On  account  of  this  increased  flexibility,  deformities  and  sometimes 
fractures  are  produced  as  the  result  of  pressure  or  weight  bearing. 

Etiology. — While  there  is  but  little  doubt  that  rickets  is  due  to  a 
disturbance  of  the  metabolism,  chiefly  of  calcium  and  phosphorus, 
and  that  the  bony  changes  are  due  to  some  interference  with  the 
deposition  of  lime  salts,  it  is  still  a  fact  that  the  cause  of  rickets  is 
not  positively  known.  Many  theories  have  been  advanced,  how- 
ever, as  to  its  causation,  all  of  which  have  a  certain  amount  of 
evidence  in  their  favor. 

Considerable  importance  has  been  attached  to  heredity  as  a 
predisposing  factor  in  the  etiology.  It  is  believed  that  the  pre- 
disposition is  transmitted  especially  through  the  mother.  Siegert  ^ 
is  the  chief  exponent  of  this  theory.  It  has,  however,  received  but 
little  support. 

Another  theory  is  that  it  is  due  to  improper  hygienic  surround- 
ings and  lack  of  fresh  air  and  sunlight.  Evidence  in  favor  of  this 
theory  is  that  it  is  more  common  in  the  city  than  in  the  country, 
in  the  winter  than  in  the  summer,  in  the  poor  than  in  the  well-to- 
do.  It  is  also  apparently  more  common  in  this  country  in  those 
races  whose  new  surroundings  are  most  different  from  those  to 
which  they  were  accustomed.  The  children  of  a  pastoral  race  are 
most  likely  to  develop  it  when  confined  to  a  city.  This  is  also 
true  of  wild  animals.  They  never  have  the  disease  when  free,  but 
often  develop  it  when  confined  in  zoological  gardens.^ 

The  most  generally  accepted  theory  is  that  it  is  caused  by  im- 
proper food.  Evidence  in  favor  of  this  theory  is  that,  other  things 
being  equal,  it  is  much  less  common  in  the  breast-fed  than  in  the 
artificially-fed,  unless  lactation  is  unduly  prolonged.  It  is  also 
more  common  when  the  artificial  feeding  is  bad  than  when  it  is 
rational. 

It  has  also  been  thought  recently  that  it  is  infectious  in  origin.* 
Certain  animal  experiments  have  seemed  to  give  positive  results. 
In  these  experiments  a  diplococcus  was  found  in  the  bones 
of  young  animals  which  were  clinically  rachitic.^    The  evidence 

1  Siegert:  Jaheb.  f.  Kinderh.,  1903,  Iviii,  929. 

2  Lehnerdt:  Ergebn.  d.  inn.  Med.  u.  Kinderh.,  1910,  vi,  120. 

'  Oppenheimer  and  Hagenbach:  Burkhardt  quoted  by  Wieland  in  Bruneg 
and  Schwalbe  Handbuch  der  Allgemeine  Pathologic  und  der  Pathologischen 
Anatomie  des  Kindesalters,  Wiesbaden,  1913,  ii,  pt.  I,  p.  260. 

*  Morpurgo:  Verhandl.  d.  Deutsch.  path.  Gesellsch.,  1900,  iii,  40,  Ibid.  1909, 
xiii,  51;  Schmorl:  Ergebn.  d.  inn.  med.  u.  Kinderh.,  1909,  iv,  403;  Koch: 
Ztschr.  f.  Hyg,  u.  Infectionskr.,  1911,  Ixix,  436. 


EXPERIMENTAL  RICKETS  331 

in  favor  of  the  infectious  origin  of  the  disease  is,  however,  not 
conclusive. 

Attempts  have  been  made  in  recent  years  to  prove  that  some 
of  the  diseases  of  metabolism,  including  rickets,  are  due  to  a  dis- 
turbance of  the  function  of  certain  of  the  glands  which  have  an 
internal  secretion. 

They  are  respectively  the  thyroid,  parathyroid,  adrenal  and 
thymus  glands  (Mettenheimer,^  Matti  ^).  Howland,  and  his  asso- 
ciates ^  repeated  the  experiments  on  animals,  using  suitable  con- 
trols, and  were  unable  to  produce  rickets  in  any  animals  in  which 
the  thjnnus  was  removed.  Renton  and  Robertson  ^  have  also 
recently  shown  that  thymusectomy  does  not  cause  any  symptoms. 
It  seems,  therefore,  as  if  the  work  upon  which  was  based  the  evi- 
dence that  the  thymus  had  some  etiological  relation  to  rickets, 
was  not  properly  carried  out. 

Kassowitz  ^  believes  that  the  increased  vascularity  of  the  bone 
marrow  and  epiphyses  is  the  principal  feature  of  rickets  and  ex- 
plains the  abnormally  wide  zone  of  growth,  and  that  these  blood 
vessels  erode  the  bone. 

Artificial  Rickets  in  Animals. — Most  investigators  who  have 
undertaken  to  reproduce  rickets  in  animals  have  assumed  that  it 
is  due  to  some  disturbance  in  the  calcium  metabolism.  They  have 
assumed  that  it  results  from  a  calcium  starvation  because  of  too 
little  calcium  in  the  food,  that  there  is  sufficient  calcium  in  the 
food  but  for  some  reason  it  is  not  absorbed  in  normal  amounts,  or 
finally  that  it  is  absorbed  in  normal  amounts  but  the  bones  are 
unable  to  utilize  it  in  the  normal  manner.  Experiments  on  animals 
have  given  varying  results.  In  most  instances  when  animals  have 
been  fed  on  a  food  deficient  in  calcium,  on  an  acid  food  or  on  a 
combination  of  the  two,  they  have  become  clinically  rachitic  ®  with 
enlarged  epiphyses.  The  microscopic  appearance  of  such  bones 
differs  from  that  in  true  rickets  in  that  the  zone  of  proliferation  is 
much  narrower.  Miwa  and  Stoeltzner's  ^  experiments  lead  them 
to  differentiate  this  condition  from  true  rickets  in  infants  and  they 
give  it  the  name  of  pseudorachitic  osteoporosis.  The  bones  from 
such  animals  have  a  very  low  ash  and  calcium  content,  but  have 
not  lost  relatively  as  much  magnesium  as  the  bones  in  true  rickets. 

^  Quoted  by  E.  Wieland,  loc.  cit. 

*  Matti:  Mitt,  aus  den  Grenzgebieten  der  Med.  u.  Chir.,  1911-12,  xxiv,  665. 
»  Howland:  Trans.  Am.  Ped.  Soc,  1914,  xxvi,  274. 

*  Renton  and  Robertson:  Journ.  Path,  and  Bacteriol.,  1916,  xxi,  1. 
»  Kassowitz:  Jahrb.  f.  Kinderh.,  1912,  N.  F.  bcxvi,  369. 
•Schmorl:  Ergebn.  d.  inn.  Med.  u.  Kinderh.,  1909,  iv,  403. 

'  Miwa  and  Stoeltzner*.  Beitr.  z.  path.  Andt.  u.  allg.  Path.,  1898,  zziv,  578. 


332  CALCIUM  METABOLISM 

In  the  former  the  loss  of  phosphoric  acid  goes  hand  in  hand  with 
the  loss  of  calcium,  while  in  the  latter  there  is  relatively  less  phos- 
phorus lost  than  calcium. 

Aron  and  Sebauer  ^  produced  artificial  rickets  in  dogs  without 
changing  the  calcium  content  in  the  muscles,  although  that  in  the 
bones  was  greatly  diminished.  This  fact  will  be  referred  to  again 
in  the  discussion  of  human  rickets. 

Calcium  Metabolism  in  Health  and  in  Rickets.^ — The  skeleton 
of  a  newly-born  baby,  weighing  2600  grams,  weighs  445  grams, 
the  muscles  625  grams,  the  skin  379  grams,  and  the  brain  342 
grams.^  The  dried  bones  of  a  newly-born  infant  contain  60% 
to  65%  of  ash  and  40%  to  45%  of  organic  material.  The  amount 
of  ash  in  the  bone  varies  from  birth  onward.  At  first  the  ash 
increases,  but  during  the  second  year  it  decreases  to  about  55%, 
with  a  corresponding  increase  in  the  organic  material.  At  the 
end  of  the  second  year  the  ash  again  begins  to  increase  until  it 
reaches  the  68%  of  the  dried  bone  substance  found  in  adults.* 
The  calcium  oxide  is  distributed  through  the  body  in  the  following 
manner:  muscles  0.03%,  skin  0.02%,  brain  0.107%  and  skeleton 
5.4%.  There  is  in  the  whole  body  25  grams  of  CaO.^  Camerer 
and  Soldner  ®  give  1.019  grams  to  every  100  grams  of  body  weight 
as  the  average  amount  of  CaO  in  the  newly-born. 

Schabad  ^  says  that  the  weight  of  the  skeleton  is  16%  of  the 
total  body  weight  during  the  first  year  of  life.  The  calcium  con- 
tent of  the  skeleton  is  1.25%  of  the  body  weight  and  7.7%  of  the 
skeletal  weight.  The  largest  deposit  of  calcium  takes  place  during 
the  period  of  greatest  growth,  viz.,  in  the  breast-fed  infant  be- 
tween the  second  and  fourth  months  and  in  the  bottle-fed  infant 
between  the  second  and  sixth  months. 

Calcium  in  Milk. — Examination  of  the  metabolism  experiments 
in  rickets  shows  that  in  artificial  feeding  the  amount  of  calcium 
usually  given  is  so  large  that  there  is  no  possibility  of  a  calcium 
deficit  in  the  food.  When  the  infant  is  fed  with  human  milk,  the 
situation  is  different.  The  percentage  of  calcium  may  vary  from 
0.03%  to  0.08%,  the  lower  limit  of  that  taken  by  healthy  nurslings 

*  Aron  and  Sebauer:  Biochem.     Zeitschr.,  1908,  viii,  I. 

*  Much  of  this  section  is  taken  from  Orgier:  Ergeb.  d.  inn.  Med.  u.  Kinderh., 
1912,  viii,  142. 

»  Vierordt:  Gerhardt's  Handb.  d.  Kinderh.,  1877,  i,  53. 

*  Schabad:  Arch.  f.  Kinderh.,  1909-10,  lii,  47. 

"  Brubacher:  Zeitschr.  f.  Biol.,  1890,  xxvii,  517. 

« Camerer  and  Soldner:  Zeitschr.  f.  Biol.,  xxxix,  173;  xl,  1900,  529;  1902, 
xliii,   1. 

7  Schabad:  Arch.  f.  Kinderh.,  1910,  liii,  380. 


CALCIUM  METABOLISM  333 

being  about  0.034%,  while  the  average  is  about  0.044%.  The 
calcium  content  of  milk  decreases  as  lactation  progresses  from 
0.045%  to  0.031%.^  It  is  clear,  therefore,  that  the  milk  secreted  in 
early  lactation  will  have  a  higher  percentage  than  that  in  later 
lactation.  This  does  not  necessarily  mean  that  the  total  daily 
amount  of  calcium  received  will  be  any  different  in  early  and  late 
lactation,  because  in  early  lactation  less  milk  is  secreted  than  in 
later  lactation.  This  may  explain  the  fact  why  one  nursling  devel- 
oped rickets  on  0.04%  of  CaO. 

Dibbelt  ^  reports  that  he  was  able  to  increase  the  CaO  content 
in  human  milk  by  giving  Ca  to  the  mother,  but  no  subsequent 
investigators  have  been  able  to  confirm  these  results.^ 

Calcium  Requirements  of  Infants. — Orgler  concludes  after  a 
long  discussion  that  unless  an  infant  absorbs  at  least  0.13  grams 
of  CaO  per  day  it  will  become  rachitic.  It  must  be  borne  in  mind, 
however,  that  Tobler  and  Noll's  *  baby  absorbed  only  0.054  grams 
and  yet  did  not  acquire  rickets.  The  average  of  the  amount  of  cal- 
cium taken  by  all  infants  is  between  0.17  grams  and  0.18  grams. 
The  normal  infant  takes  as  a  rule  only  as  much  calcium  from  hu- 
man milk  as  it  requires  for  growth.  ^  It  must  be  remembered  in  this 
connection,  however,  that  the  amount  of  some  of  the  other  food 
components  may  be  so  disproportionately  high  (for  example  fat) 
that  the  infant  receives  so  many  calories  in  a  concentrated  food 
that  it  does  not  take  enough  in  amount  to  give  it  the  amount  of 
calcium  it  requires,  even  though  the  percentage  of  calcium  is 
within  normal  limits.  Infants  have  been  reported  to  become  ra- 
chitic receiving  0.088%  CaO. 

Calcium  Metabolism. — The  methods  of  quantitating  the  salts 
in  the  food  and  excretions  of  the  body  are  very  diflficult  and  certain 
authorities  say  that  they  are  all  unreliable  with  the  exception  of 
Macrudden's  method  for  calcium.  Since  there  is  so  much  doubt 
as  to  the  accuracy  of  the  methods  used  in  obtaining  the  following 
information,  it  must  all  be  considered  with  the  inaccuracies  well 
in  mind. 

Calcium  is  in  the  milk  principally  in  organic  combination.  Both 
organic  and  inorganic  calcium  may  be  absorbed  by  the  body.  The 
calcium  in  the  food  goes  into  solution  in  the  stomach.    From  5%  to 

1  Bahrdt  and  Edelstein:  Jahrb.  f.  Kinderh.,  1910,  Ixxii,  16  (SuppL);  Schabad: 
Jahrb.  f.  Kinderh.,  1911,  Ixxiv,  511. 

» Dibbelt:  Ziegler's  Beitr.,  1910,  xlviii,  147. 

»  Bahrdt  and  Edelstein:  Jahrb.  f.  Kinderh,,  1910,  Ixxii,  16  (Suppl.);  Schabad: 
Jahrb.  f.  Kinderh.,  1911,  Ixxiv,  511. 

< Tobler  and  Noll:  Monatsschr.  f.  Kinderh.,  1910-11,  ix,  210. 

•Aron:  Biochem.  Zeitschr.,  1908,  xii,  28. 


334 


CALCIUM  METABOLISM 


10%  of  it  appears  in  the  urine  after  absorption,  while  the  rest  of  the 
calcium  that  is  not  retained  in  the  body  is  excreted  through  the 
feces.  This  may  pass  directly  through  the  intestines  into  the  feces 
or  indirectly,  viz. :  it  may  be  absorbed  in  the  small  intestine  and 
excreted  again  in  the  large  intestine.^  Most  of  the  calcium  ex- 
creted in  the  urine  is  combined  with  phosphoric  acid,  but  a  small 
amount  is  combined  with  carbonic,  sulphuric  and  uric  acids.'^ 

The  most  striking  fact  in  the  chemistry  of  rickets  is  that  the 
bones  in  rickets  as  compared  to  the  normal  have  a  diminished 
amount  of  calcium  and  phosphorus  and  an  increased  amount  of 
water.  The  following  table  taken  from  Orgler  ^  illustrates  this  fact 
very  well: 

This  table  was  compiled  by  Orgler  from  Schabad :  * 


TABLE  49 


Normal 
Ribs  Occiput 


Rachitis 
Ribs  Occiput 


Water 

Organic  substances 

Ash 

CaO 

P2O5 


14.4-32.9 
26.9-39.1 
40.2-46.6 
21.7-25.3 
12.3-18.9 


13.0-16.1 
32.2-36.5 
47.6-51.7 
26.3-27.9 
18.1-20.7 


42.4-66.4 

20.7-27.4 

7.9-32.0 

4.2-16.8 

3.3-12.8 


29.0-35.9 
26.1-31.6 
34.3-40.6 
19.0-24.1 
13.7-17.8 


These  changes  are  less  marked  in  mild  than  in  severe  rickets. 

The  Influence  of  the  Other  Food  Components  on  the  Calcium 
Metabolism. — Proteins. — There  are  very  few  experiments  that  have 
any  bearing  on  the  subject,  but  those  that  can  be  utilized  ^  seem  to 
show  that  the  proteins  have  no  influence  on  the  calcium  retention. 

Fat. — ^According  to  some  writers  fat  has  a  marked  influence  on 
the  calcium  metabolism,  as  increased  amounts  cause  a  negative 
calcium  balance.^  The  following  table  from  Orgler  serves  to  il- 
lustrate this  point: 


^  First  shown  in  dogs  by  E.  Voit:  Zeitschr.  f.  Biol.,  1880,  xvi,  55. 

*  Albu-Neuberg:  Mineralstofifwechsel,  Berlin,  1906,  116. 

3  Made  up  from  figures  of  Schabad:  Arch  f.  Kinderh.,  1909-1910,  lii,  47,  63; 
1910,  mi,  380:  1910,  liv,  83. 

*  Schabad:  Zur  Bedeutung  des  Kalkes  in  der  Pathologic  der  Rachitis:  Arch, 
f.  Kinderh.,  1910,  lii,  47  and  63;  1910,  liii,  380;  1910,  Uv,  83. 

5  Tada:  Monatsschr.  f .  Kinderh.,  1905-06,  iv,  118. 
« Freund:  Jahrb.  f.  Kinderh.,  1905,  bd,  36. 


CALCIUM  METABOLISM 


335 


TABLE   50 


/.  Groeger 
(a)  skim  milk 
N            CaO 

Rothberg  ' 

(b)  cream 

N            CaO 

Steinitz  11,^ 
milk         cream 
CaO           CaO 

Food 

Urine 

Feces 

2.963 
2.499 
0.315 

0.975 
0.020 
0.818 

3.400 
2.625 
0.381 

0.927 

0.0 

1.125 

0.398 
0.005 
0.355 

0.378 

0.0 

0.412 

Balance .... 

+0.149 

+0.137 

+0.394 

-0.198 

+0.038 

-0.034 

In  other  instances  increasing  amounts  of  fat  in  the  food  have 
no  influence  on  the  Ca  metabolism,  as  is  shown  by  the  following 
work  of  Freund :  ^ 

TABLE  51 


Arndl 

*/i2  milk 

water 

CaO 

Whole 
milk 
CaO 

Steinitz 
Yi  milk 
CaO 

Cream 
CaO 

Food 

0.478 

0.0 

0.409 

0.857 
0.022 
0.467 

0.414 
0.387 

0.314 

Urine 

Feces 

0.216 

Balance 

+0.069 

+0.368 

+0.027 

+0.098 

Carbohydrates. — Up  to  recently  there  were  no  experiments  free 
from  error  showing  the  influence  of  carbohydrate  on  the  reten- 
tion of  calcium.  In  1913  Rowland  ^  reported  the  results  of  a  study 
of  the  calcium  metabolism  as  it  was  influenced  by  carbohydrates. 
A  milk  mixture  without  any  carbohydrate  was  followed  by  a  very 
slight  positive  or  by  a  negative  balance  of  calcium.  When  the 
same  mixture  was  given  with  carbohydrate  added,  even  though 
the  carbohydrate  was  a  small  quantity  of  cereal,  a  positive  calcium 
balance  often  resulted,  and  when  sugar  was  given  the  calcium  bal- 
ance was  practically  always  positive.  This  work  seems  to  indicate 
that  carbohydrate  has  a  very  marked  influence  on  the  retention  of 
calcium.  There  are  no  figures  to  show  what  effect  an  excess  of  car- 
bohydrate has  on  the  calcium  metabolism. 

Salts. — There  are  no  studies  to  show  the  effect  of  the  sodium  or 

'  Rothberg:  Jahrb.  f.  Kinderh.,  1907,  Ixvi,  69. 
''Steinitz:  Jahrb.  f.  Kinderh.,  1903,  Ivii,  689. 

•  Freund:  loc.  cit. 

*  Howland  and  Marriott:  Am.  J.  Obstet.,  1916,  bcxiv,  541. 


336  CALCIUM  METABOLISM 

potassium  salts  on  the  retention  of  calcium  in  infants.  The  effect 
of  an  absence  of  organic  material  in  the  food,  as  in  fasting,  is  also 
unknown. 

Cronheim  and  Miiller^  reported  that  boiling  milk  influenced 
the  calcium  retention,  but  Arndt,^  who  used  better  methods, 
showed  that  boiling  had  no  effect  on  the  retention  of  calcium. 

During  the  early  stage  of  florid  rickets  ^  the  calcium  balance  is 
either  diminished  or  negative.  This  disturbance  in  the  calcium 
metabolism  may  be  present  some  time  before  the  appearance  of 
any  of  the  clinical  signs  of  rickets.^  As  the  disease  becomes  well 
developed,  the  calcium  balance  is  either  below  the  average  or 
within  normal  limits.  When  convalescence  or  cure  commences 
there  is  a  greatly  increased  retention  of  calcium,  which  shows  itself 
earlier  than  does  clinical  improvement.  During  this  period  two  or 
three  times  as  much  calcium  is  retained  as  in  the  normal,  and  when 
cure  is  complete  the  calcium  retention  again  becomes  normal. 

The  increased  excretion  of  calcium  from  the  body  in  florid  rick- 
ets goes  on  exclusively  through  the  intestines,  while  at  the  same 
time  there  is  less  calcium  than  usual  excreted  through  the 
urine.  ^ 

Phosphorus  metabolism  like  the  calcium  metabolism  is  influenced 
by  the  kind  of  food  given.^  There  is  relatively  so  much  phos- 
phorus excreted  that  it  cannot  all  come  from  the  bones  and  pre- 
sumably comes  from  the  nervous  system,^  The  relation  between 
the  urinary  and  fecal  phosphorus  in  healthy  nurslings  is  80:20  and 
in  rachitic  nurslings  65:35,  while  in  the  healthy  bottle-fed  infant  it 
is  60:40  and  the  rachitic  artificially-fed  40:60.  During  conva- 
lescence from  rickets  the  total  excretion  of  phosphorus  is  lower 
than  normal,  and  the  relation  of  the  urinary  to  the  fecal  phos- 
phorus returns  to  the  normal  figures.  Calcium  is  excreted  in  the 
JFeces  with  phosphoric  acid  or  fatty  acid,  and  it  is  conceivable  that 
an  increase  of  either  of  these  substances  may  increase  the  calcium 
excretion. 

Analyses  of  both  rachitic  and  healthy  bones  show  that  the  com- 
plex salt  Cas  (P04)2  2CaC03is  the  same  in  both  instances.  Pota- 
sium,  sodium  and  chlorine  are  the  same  in  both.    Magnesium  is 

^  Cronheim  and  Miiller:  Jahrb.  f.  Kinderh.,  1903,  Ivii,  45, 
^  Quoted  by  Orgler — loc.  cit. 
3  Schabad:  Arch.  f.  Kinderh.,  1910,  liii,  380. 
*  Birk  and  Orgler:  Monatsschr.  f.  Kinderh.,  1910-11,  ix,  544. 
»  Schabad:  Arch.  f.  Kinderh.,  1910,  liii,  380;  Dibbelt:  Verhandl.  der  Deutsch. 
path.  Gesellsch.,  1910,  xiv,  294. 

« Albu  and  Neuberg:  loc.  cit.,  p.  144. 

7  Schabad:  Arch.  f.  Kinderh.,  1910,  Uv,  83. 


TREATMENT  337 

increased  from  0.50%  in  the  normal  bone  to  0.53-0.74%  in  rachitic 
bone.* 

The  muscles  in  rickets  give  evidence  of  the  calcium  loss  from 
the  body.  They  contain  less  calcium  than  do  normal  muscles,^ 
the  amount  of  the  deficiency  varying  directly  with  the  severity 
of  the  disease. 

The  calcium  content  of  the  other  organs  is  not  diminished  in 
rickets.  Pathologically,  rachitic  muscles  show  an  excessive  thin- 
ning of  the  muscle  fibers  with  loss  of  striation,  accompanied  by  an 
increase  in  the  number  of  cell  nuclei.  These  changes  are  most 
marked  in  the  most  severe  cases.  The  blood  in  rickets  shows  very 
little  or  no  diminution  in  its  calcium  content.^ 

Treatment. — What  little  evidence  there  is  derived  from  experi- 
ments on  animals  goes  to  show  that,  while  deficiency  of  calcium 
in  the  food  causes  a  disturbance  in  the  ossification  of  the  bones,  it 
does  not  produce  rickets.  It  is  evident,  moreover,  from  the  figures 
which  have  just  been  given,  that  there  never  is  a  deficiency  of 
calcium  in  artificial  foods,  of  which  cow's  milk  forms  the  basis. 
There  is,  therefore,  no  justification  whatever  for  giving  calcium  to 
rachitic  babies  that  are  taking  cow's  milk.  It  is  barely  possible, 
but  extremely  improbable,  that  a  nursing  baby  may  not  get  enough 
calcium  in  its  food.  Judging  from  the  results  of  animal  experi- 
mentation, such  a  deficiency  would  not,  however,  cause  rickets. 
Nevertheless,  it  might  be  justifiable  to  give  a  breast-fed  rachitic 
baby  some  form  of  calcium.  There  is  no  evident  reason  why  one 
form  of  calcium  should  not  be  as  useful  as  another  under  these 
circumstances.  In  any  event,  only  a  small  amount  would  be 
required.  It  is  probably  useless  to  attempt  to  increase  the  calcium 
in  the  milk  by  giving  calcium  to  the  mother.  If  rachitic  babies  are 
taking  neither  human  milk  nor  cow's  milk  and  are,  therefore,  not 
getting  enough  calcium  in  their  food,  they  should  be  given  one  or 
the  other.  It  will  then  be  unnecessary  to  give  them  calcium.  It  is 
possible  that  a  baby  that  is  taking  a  very  rich  food  may  take  so 
little  of  it  that  it  does  not  get  enough  calcium.  The  remedy  for 
this  condition  is  to  dilute  the  food  so  that  the  baby  will  take  more 
of  it,  rather  than  to  give  calcium. 

There  are  very  few  data  as  to  the  relation  of  the  other  food  ele  • 
ments  to  the  metabolism  of  calcium.  It  is  possible  that  the 
presence  of  a  large  excess  of  fat  in  the  food  may,  by  combining 
with  the  calcium  in  the  food,  interfere  with  its  absorption  and, 

^Gassmann:  Hoppe-Seyler's  Zeitschr.  f.  Phys.  Chem.,  1910-1911,  Ixx,  16?. 
^  Aschenheim  and  Kaumheimer:  Monatsschr.  f.  Kinderh.,  1911-12,  x,  435. 
»  Rowland  and  Marriott:  Tr.  Am.  Ped.  Soc,  1916,  xxviii,  200. 


338  TREATMENT 

therefore,  with  its  retention.  The  evidence  as  to  this  fact  is,  how- 
ever, inconclusive.  There  is,  on  the  other  hand,  a  certain  amount 
of  evidence  which  goes  to  show  that  the  addition  of  a  carbohydrate, 
whether  sugar  or  starch,  to  a  food,  the  basis  of  which  is  cow's  milk, 
favors  the  retention  of  calcium.  Variations  in  the  amount  of  pro- 
tein in  the  food  have  no  apparent  effect  on  the  metabolism  of 
calcium,  but  it  must  be  remembered  in  this  connection  that  a 
large  part  of  the  calcium  in  milk  is  in  combination  with  protein,  a 
deficiency  of  which  might  cause  a  deficiency  of  calcium.  Neither 
do  variations  in  the  amount  of  sodium  and  potassium.  There  are 
no  data  as  to  the  effect  of  variations  in  the  amount  of  the  other 
salts. 

Other  things  being  equal,  rickets  is  much  less  common  and  much 
less  severe  in  breast-fed  than  in  artificially-fed  babies.  The  best 
food  for  the  rachitic  baby  is,  therefore,  good  human  milk.  If  this 
cannot  be  obtained,  the  next  best  food  must  be  selected.  This  is, 
necessarily,  some  form  of  modified  cow's  milk.  There  are  no  very 
definite  general  indications,  based  on  our  knowledge  of  the  metabo- 
lism in  rickets,  as  to  what  the  composition  of  this  food  should  be. 
What  httle  experimental  evidence  there  is,  however,  suggests  that 
it  is  advisable  to  avoid  high  percentages  of  fat  and  to  give  per- 
centages of  carbohydrates  well  up  to  the  normal  limits.  These 
points  should  be  borne  in  mind,  therefore,  in  deciding  upon  the 
composition  of  the  food.  They  are  of  but  comparatively  little 
importance,  however,  and  should  be  disregarded  if  they  conflict 
with  the  evidence  furnished  by  the  symptoms  and  stools  as  to  the 
digestive  capacity  of  the  individual  infant.  The  chief  object  in 
the  selection  of  the  food  for  the  rachitic  baby,  as  well  as  for  all 
other  babies,  is  to  fit  the  food  to  the  digestive  capacity  of  the 
individual  infant  at  the  given  time.  That  is,  the  composition  of 
the  food  for  a  rachitic  baby  should  be  decided  upon  in  the  same 
way  as  that  of  any  other  baby,  bearing  in  mind  that  perhaps  it  may 
be  advisable  to  keep  the  percentage  of  fat  lower  and  that  of  the 
carbohydrates  higher  then  would  ordinarily  be  done. 

There  has  been  much  discussion  as  to  whether  cod-hver  oil  and 
phosphorus,  either  alone  or  in  combination,  are  of  advantage  in  the 
treatment  of  rickets.  It  would  seem  fairly  definite,  however,  from 
the  experimental  data  as  to  the  effect  of  large  amounts  of  fat  in 
the  food  on  the  metabolism  and  retention  of  calcium,  that  cod- 
Uver  oil  might  not  only  do  no  good  but  perhaps  active  harm. 
Schloss  ^  has  found,  however,  that  when  cod-liver  oil  is  given  in 
connection  with  preparations  of  calcium  the  retention  of  calcium 
*  Schloss:  Jahrbuch  f.  Kinderh.,  1915,  Ixxxil,  435. 


TREATMENT  33^ 

is  much  better  than  when  either  is  given  alone.  The  evidence 
as  to  the  action  of  phosphorus,  whether  alone  or  in  combina- 
tion with  cod-liver  oil,  which  is  summed  up  briefly  below,  is 
conflicting. 

Kassowitz  *  first  recommended  phosphorus  in  the  treatment  of 
rachitis.  His  original  prescription,  known  as  phosphorleberthran 
(phosphori  0.01,  ol.  jecor  aselli,  ad  250),  still  holds  first  place  in 
Germany  in  the  treatment  of  rachitis.  Kissel  ^  found  in  his  experi- 
ments on  animals  that  phosphorus  had  absolutely  no  effect  on  the 
skeletal  system,  and  concluded  that  there  was  no  ground  for  its 
use.  Despite  this  evidence  phosphorus  continues  to  be  used  and 
many  experiments  have  been  performed  to  prove  its  eflSciency. 

Birk  ^  and  Schabad  ^  both  concluded  that  phosphorus  in  thera- 
peutic doses  does  not  affect  the  calcium  metabolism  in  healthy 
children.  Such  children  take  only  as  much  phosphorus  as  they 
need  for  growth  regardless  of  the  amount  in  the  food.  In  rachitis 
cod-fiver  oil  increases  the  retention  of  phosphorus  and  calcium  and 
this  action  is  intensified  by  the  addition  of  phosphorus  to  the  oil.^ 
The  increased  retention  of  calcium  starts  three  to  five  days  after 
giving  phosphojus  and  gradually  diminishes  until  at  the  end  of 
two  months  it  is  again  normal.  This  is  because  of  the  increased 
absorption  and  decreased  excretion  through  the  urine  and  feces. 
The  question  then  came  up  as  to  whether  oils  as  such  in  combina- 
tion with  phosphorus  have  a  therapeutic  action  on  rachitis. 
Schabad  ^  investigated  the  action  of  phosphorus,  cod-Hver  oil  and 
"sesamol"  on  the  metabolism  of  calcium,  phosphorus,  fat  and 
nitrogen  and  found  that  "sesamol"  and  phosphorus  did  not  help 
rachitis,  while  cod-liver  oil  plus  phosphorus  increased  the  retention 
of  phosphorus  and  calcium  and  the  absorption  of  fat  and  nitrogen. 
Schabad  and  Sorochowitsch  ^  used  fipanin,  which  is  a  mixture  of 
oHve  oil  and  oleic  acid  and  is  used  as  a  substitute  for  cod-liver  oil. 
It  is  supposed  to  be  easily  absorbed  because  it  contains  free  fatty 
acids.  They  concluded  from  their  metabohsm  experiments  that 
lipanin  and  oUve  oil  increase  the  absorption  of  nitrogen  and  fat 
but  that  lipanin  has  no  advantage  over  olive  oil.  Lipanin  does 
not  increase  the  retention  of  calcium  in  rachitis  and  is  therefore 
not  as  good  as  cod-fiver  oil  in  the  treatment  of  rachitis.    They 

*  Kassowitz:  Ztschj*.  f.  klin,  Med.,  1883-4,  vii,  36. 

'  Kissel:  Virchow's  Arch.  f.  path.  Anat.,  1896,  cxliv,  94. 

*  Birk:  Monatsschr.  f.  Kinderh.,  1908-09,  vii,  450. 
'Schabad:  Ztschr.  f.  khn.  Med.,  1909,  Ixvii,  454. 
'  Schabad:  Ztschr.  f.  klin.  Med.,  1909,  Ixviii,  94. 

» Schabad:  Ztschr.  f.  khn.  Med.,  1909-10,  Ixix,  435. 

*  Schabad  and  Sorochowitsch:  Monatsschr.  f.  Kinderh.,  1910-11,  ix,  659. 


340  TREATMENT 

say  in  their  most  recent  article  ^  that  sometimes  phosphorus  and 
cod-liver  oil  does  not  have  a  favorable  action  on  the  retention 
of  calcium  in  rachitis,  especially  if  the  disease  is  not  approaching  a 
convalescence.  At  other  times  it  has  a  favorable  action  on  the 
calcium  retention.  They  experimented  with  various  other  salts 
combined  with  cod-liver  oil  and  found  that  a  calcium  acetate  cod- 
hver  oil  had  the  most  favorable  action  on  rachitis  because  it  con- 
tained much  more  calcium.  Most  recently  Caroline  Towles  ^  did  a 
series  of  metabolism  experiments  in  von  Pirquet's  clinic  in  Breslau 
and  was  unable  to  demonstrate  that  phosphorus  cod-liver  oil  had 
any  action  at  all  on  acute  rachitis. 

It  is  very  difficult  to  draw  any  conclusions  from  this  evidence  as 
to  the  advisability  of  using  cod-liver  oil  and  phosphorus  in  the 
treatment  of  rickets.  It  is  probably  safe  to  conclude,  however, 
that  it  is  not  advisable  to  give  large  doses  of  cod-liver  oil  or  any 
other  fat.  It  is  also  probably  safe  to  conclude  that  phosphorus  may 
do  good  and  that,  at  any  rate,  it  does  no  harm  if  properly  used.  If 
phosphorus  is  used,  it  is  probably  best  to  give  it  in  combination 
with  cod-hver  oil.  The  best  preparation  of  phosphorus  is  phos- 
phorated oil.  A  minim  of  this  preparation  contains  about  1/115  of 
a  grain  of  phosphorus.  The  dose  for  a  baby  is  from  one-half  of  a 
minim  to  two  minims,  two  or  three  times  daily.  Too  much  should 
not,  however,  be  expected  from  it.  It  is  liable  to  disturb  the 
stomach  and  should  be  given  after  food. 

An  abimdance  of  fresh  air  and  sunlight  is  of  the  greatest  impor- 
tance in  the  treatment  of  rickets.  Everything  should  be  done  to 
improve  the  hygienic  surroundings.  Massage  undoubtedly  does 
good.  The  advantage  of  salt  baths  is  problematical.  Iron  should 
be  given,  if  there  is  anaemia.  Other  treatment  can  be  only  symp- 
tomatic. 

»  Schabad  and  Sorochowitsch:  Monatsschr.  f.  Kinderh.,  1911-12,  x,  12. 
«  Towles:  Ztschr.  f.  Kinderh.,  1910-11,  i,  346. 


CHAPTER  XXVIII 

INFANTILE  SCURVY 

Scurvy  is  a  constitutional  disease  due  to  a  disturbance  of  the 
nutrition.  The  disturbance  of  nutrition  is  the  result  of  some  pro- 
longed error  in  the  diet.  The  error  in  the  diet  is  in  all  probabiUty 
the  absence  or  marked  diminution  of  some  constituent  or  con- 
stituents of  the  food  essential  for  the  carrying  on  of  the  normal 
metabohc  processes  and  for  growth.  It  is  not  known  exactly  what 
these  constituents  are,  but  it  is  very  probable  that  they  are  of  the 
nature  of  vitamins.  The  chief  characteristic  of  the  disease  is  a 
tendency  to  hemorrhage.  Infantile  scurvy  is  the  same  disease  as 
scurvy  in  the  adult.  Scurvy  and  rickets,  although  often  asso- 
ciated, are  two  distinct  diseases. 

PATHOLOGICAL      ANATOMY 

The  bone  marrow  shows  characteristic  changes.  These  are  most 
marked  at  the  ends  of  the  diaphyses  of  the  long  bones  and  the  an- 
terior ends  of  the  ribs.  The  bone  marrow,  which  is  normally  rich 
in  lymphoid  cells,  loses  it  lymphoid  character  and  is  converted  into 
a  tissue  poor  in  cellular  elements,  that  contains  relatively  few 
blood  vessels.  This  tissue  consists  of  a  homogeneous  ground  sub- 
stance containing  spindle  and  stellate  cells.  There  is  still  much 
calcified  ground  substance,  but  it  has  not  been  converted  into 
true  bone.  As  a  result  of  the  interference  with  the  normal  proc- 
esses of  ossification,  the  cortex  of  the  bones  is  thinner  and  more 
brittle  than  normal  and  the  density  of  the  bone  is  materially  di- 
minished at  the  epiphyseal  fine.  Fractures  of  the  shafts  occur 
very  readily,  therefore,  as  the  result  of  very  slight  injuries.  These 
occur  most  often  at  or  near  the  epiphyseal  lines.  The  epiphyses 
are  often  loosened  and  separated.  Marked  displacement  of  the 
epiphysis,  is,  however,  imconmion  because  the  periostemn  usually 
remains  intact. 

The  periosteum  of  the  long  bones  is  thickened  and  congested, 
but  shows  no  excess  of  leucoctyes  or  small  round  cells.  Hem- 
orrhages between  the  periosteum  and  the  bone  are  very  common 
and  may  be  very  extensive.    They  may  break  through  the  perios- 

341 


342  INFANTILE  SCURVY 

teum  into  the  surrounding  tissues.  Small  hemorrhages  in  the 
marrow  of  the  bones  are  also  probably  not  at  all  uncommon,  but 
can  hardly  be  recognized  clinically.  Subperiosteal  hemorrhages 
are  much  more  common  in  the  lower  than  in  the  upper  ex- 
tremities. 

Hemorrhages  may  occur  in  any  of  the  internal  organs.  They  are 
common  in  the  skin  and  are  found  at  autopsy  in  most  of  the  serous 
membranes.  They  may  also  occur  in  the  intestinal  mucosa. 
Hematuria,  without  inflammatory  changes  in  the  kidney,  is  com- 
mon. A  hemorrhagic  condition  of  the  gums  is  a  common  symptom 
when  the  teeth  have  erupted.  It  is,  however,  very,  uncommon 
before  the  teeth  have  appeared.  Hemorrhage  sometimes  takes 
place  in  the  orbit,  pushing  the  eye  forward,  also  under  the  dura 
or  into  the  joints. 

There  is  enlargement  of  the  heart  in  many  instances.  The  right 
ventricle  is  chiefly  involved  and  the  enlargement  is  more  often  due 
to  dilatation  than  to  hypertrophy.^ 

Hess  and  Fish  ^  have  recently  made  a  study  of  the  blood  in  this 
disease  to  determine  the  cause  of  the  hemorrhages.  They  found 
that  the  clotting  power  of  the  blood  in  scurvy  was,  as  a  rule, 
slightly  diminished.  This  diminution  was  not,  however,  constant 
and  cannot,  therefore,  be  regarded  as  an  essential  manifestation 
of  the  disease  or  sufficient  to  account  for  the  hemorrhagic  tendency 
so  characteristic  of  it.  They  found  that  there  was  no  deficiency  of 
calcium  or  blood-platelets  and  no  excess  of  antithrombin.  They 
then  studied  the  blood  vessels  by  means  of  what  they  term  the 
"capillary  resistance  test"  and  found  that  there  was  a  weakness 
of  the  vessel  walls  in  scurvy.  This  weakness  is  also  present  in 
other  conditions  than  scurvy  and  is,  therefore,  not  pathognomonic 
of  it.  It  seems  evident  from  their  work,  however,  that  the  hemor- 
rhagic tendency  in  scurvy  is  due  to  a  weakness  of  the  vessel  walls 
rather  than  to  any  change  in  the  blood.  A  firm  edema,  infiltrating 
the  skin  and  muscles,  not  pitting  on  pressure,  and  most  marked 
in  the  lower  extremities  is  not  uncommon  and  is  also  probably  due 
to  a  nutritional  disturbance  of  the  smaller  vessels.' 

The  increase  in  the  rate  of  the  pulse  and  respiration,  the  exagger- 
ated knee-jerks,  and  the  oedema  of  the  optic  disks  which  has  been 
found  in  some  cases,  suggest  very  strongly  that  the  nervous  sys- 
tem is  also  involved.^ 

^  Hess:  Journ.  Amer.  Med.  Ass.,  1915,  Ixv,  1003. 

*  Amer.  Jour.  Diseases  of  Children,  1914,  viii,  385. 
'Hess:  Journ.  Amer.  Med.  Ass.,  1915,  Ixv,  1003. 

*  Hess:  Journ.  Amer.  Med.  Ass.,  1917,  Ixviii,  235. 


INFANTILE  SCURVY  343 

ETIOLOGY 

Certain  facts  are  definitely  known  as  to  the  etiology  of  scurvy. 
One  of  them  is  that  it  occurs  most  frequently  in  the  last  half  of  the 
first  year  and  in  the  first  quarter  of  the  second  year.  More  than 
four-fifths  of  the  cases  develop  during  this  period  and  half  of  them 
between  the  seventh  and  tenth  months.  It  has  been  seen,  however, 
in  infants  under  one  month  old  and  occasionally  develops  during 
the  third  and  fourth  years.  It  is  also  true  that  the  hygenic  sur- 
roundings have  no  influence  on  its  occurrence.  The  previous  con- 
dition of  health  is  unimportant  and  diseases  of  the  digestive  tract 
do  not  predispose  to  its  development.  Jackson  and  Moody  ^ 
and  McCollum  and  Pitz^  have  recently  called  attention  to  the 
possibility  that  bacteria  may  be  the  cause  of  scurvy.  They 
furnish,  however,  no  evidence  in  any  way  satisfactory  to  prove 
that  it  is  microbic  in  origin. 

CUnical  experience  apparently  proves  conclusively  that  scurvy 
is  caused  by  some  error  in  the  diet.  Furthermore,  it  seems  to  prove 
that  it  is  due  to  some  prolonged  error  in  diet  rather  than  to  a  tem- 
porary unsuitability  of  the  food.  The  analysis  of  a  considerable 
series  of  cases  seems  to  show,  moreover,  that  the  disease  is  due  to 
the  lack  of  some  essential  element  in  the  food  rather  than  to  the 
presence  of  some  abnormal  element  or  elements.  Further  than 
this  the  cUnical  evidence  is  rather  unsatisfactory.  It  is  true  that 
scurvy  is  infinitely  more  common  in  artificially-fed  infants  than  in 
the  breast-fed.  It  does  occur,  however,  in  the  breast-fed.  This 
proves  that  it  is  not  due  simply  to  the  lack  of  breast-milk.  It  oc- 
curs very  frequently  in  babies  that  are  taking  proprietary  foods 
prepared  without  milk.  It  occurs  also  in  babies  that  are  taking  the 
proprietary  foods  prepared  with  milk  and  in  babies  that  are  taking 
milk  without  the  addition  of  proprietary  foods.  These  facts  show 
that  scurvy  cannot  be  due  simply  to  the  presence  of  the  proprietary 
foods  or  to  either  the  presence  or  absence  of  milk  in  the  diet. 
Scurvj'  occurs  in  babies  that  are  taking  condensed  milk,  boiled 
milk,  pasteurized  milk  and  raw  milk,  which  apparently  shows  that 
the  heating  of  milk,  even  if  it  is  a  factor  in  the  production  of  scurvy, 
is  not  the  only  cause.  The  report  of  the  Committee  of  the  Amer- 
ican Pediatric  Society  in  1898  emphasizes  the  difficulties  in  ar- 
riving at  the  dietetic  cause  or  causes  of  scurvy.  They  were  only 
able  to  arrive  at  the  conclusion,  after  a  careful  analysis  of  379  cases, 
that  "the  farther  a  food  is  removed  in  character  from  the  natural 

^Jackson  and  Moody:  Journ.  Infect.  Dis.,  1916,  xix,  511. 
*  McCollum  and  Pitz :  Journ.  Biolog.  Chem.,  1917,  xxxi,  229. 


344  ETIOLOGY 

food  of  a  child  the  more  likely  its  use  is  to  be  followed  by  the  devel- 
opment of  scurvy."  *  The  analysis  of  the  authors'  own  cases  shows 
the  same  discrepancy  in  the  foods  which  were  being  taken  when 
scurvy  developed  that  has  been  found  in  all  other  series.  It  seems 
to  show  also,  however,  that  the  absence  of  "freshness"  and  the 
heating  of  the  food  are  very  important  elements  in  the  production 
of  scurvy.  In  the  more  recent  cases,  overheating  of  the  food  was 
found  in  a  larger  proportion  of  the  cases  than  was  any  other  of  the 
conditions  to  which  it  has  been  thought  scurvy  may  be  due.^ 

Effect  of  Heat. — It  is  very  difficult  to  draw  any  positive  conclu- 
sions from  the  literature  of  the  subject  as  to  whether  the  heating 
of  milk,  whether  to  the  temperature  of  pasteurization  or  to  that  of 
boiling,  produces  scurvy  in  infants.  The  evidence  presented  is 
conflicting  and  inconclusive.  In  most  instances  the  number  of 
infants  studied  is  small  and  the  data  as  to  the  degree  and  duration 
of  the  heating  are  incomplete.  The  statistics  of  Variot  ^  and  Carel  ^ 
which  are  always  brought  forward  to  show  that  the  heating  of  milk 
does  not  cause  scurvy,  are  of  little  or  no  value,  because  at  the  time 
when  these  observations  were  made  scurvy  was  not  sufficiently 
well  known  in  France  to  be  recognized  unless  of  a  most  extreme 
type.  The  strongest  evidence  against  the  heating  of  milk  being  the 
cause  of  scurvy  is  found  in  the  work  of  Lane-Claypon  in  the  Infant 
Consultation  of  the  Naunyn  Strasse  in  Berlin,  in  which  a  consider- 
able series  of  babies  were  fed  on  boiled  milk  for  long  periods  and 
did  not  develop  scurvy.^ 

The  strongest  clinical  evidence  in  favor  of  the  view  that  the 
heating  of  milk  produces  scurvy  is  the  fact  that  all  large  series  of 
cases  of  scurvy  show  that  a  considerable  proportion  of  the  patients 
were  fed  on  heated  milk,  more  of  them,  however,  on  sterilized, 
boiled  or  scalded,  than  on  pasteurized  milk.®  It  is  impossible  to 
prove,  however,  that  it  was  the  heating  of  the  milk  and  not  the 
composition  of  the  food  which  caused  the  scurvy  in  these  babies. 
It  is  evident  that  when  an  individual  baby  is  fed  on  a  heated  mod- 

^  Archives  of  Pediatrics,  1898,  xv,  481. 

2  Morse:  Jour.  Amer.  Med.  Assn.,  1996,  xlvi,  1073,  Boston  Medical  and 
Surgical  Journal,  1914,  clxx,  504,  and  transect.  Amer.  Ped.  Soc,  1914,  xxvi, 
61. 

'  Variot:  Compt.  rend.  Acad.  d.  Sci.,  1904,  cxxxix,  p.  1002. 

*  Carel:  Le  lait  sterilise.    ThSse  de  Paris,  1902-3. 

^  Reports  to  the  Local  Government  Board  on  Public  Health,  1912,  New 
Series,  No.  63.  The  Uterature  of  the  subject  up  to  this  time  is  given  in  this 
article. 

6  Sill:  Medical  Record,  1902,  Ixii,  1016;  Hess  and  Fish:  Amer.  Jour.  Dis.  of 
Children,  1914,  viii,  385;  Morse,  loc.  cit:  Report  Amer.  Ped.  Soc'y  Archives 
of  Pediatrics,  1898,  xv,  481. 


ETIOLOGY  345 

ified  milk  it  is  impossible  to  know,  if  scurvy  develops,  whether  it  is 
due  in  the  special  case  to  the  heating  or  to  the  composition  of  the 
milk.  It  can  be  only  a  matter  of  opinion.  Further  evidence  against 
the  heating  of  milk  causing  scurvy  is  that  scurvy  sometimes  devel- 
ops in  the  breast-fed  and  in  babies  fed  on  raw  milk.  Still  further 
evidence  are  Plantanza's  observations  ^  that  although  scurvy  de- 
veloped more  frequently  in  babies  fed  on  heated  milk  which  was 
not  used  at  once  than  on  raw  milk,  it  did  not  develop  when  fresh 
milk  was  heated  and  used  at  once. 

The  results  of  experiments  on  animals  with  raw  and  heated  milk 
are  few  and  inconclusive.  So  many  other  factors  have  entered  into 
the  experiments  that  the  results  are  practically  without  value. 
Frolich  ^  was  able  to  produce  scorbutus  in  guinea  pigs  by  exclusive 
feeding  with  either  raw  or  cooked  cow's  milk,  although  not  as  per- 
fectly as  by  exclusive  grain  feeding.  When  fed  on  oats  and  raw 
milk  they  did  not  develop  scorbutus,  but  when  fed  on  oats  and 
cooked  milk  they  did.  Bolle,  and  after  him  Bartenstein,^  tried  the 
effect  of  heating  milk  and  found  that  heating  it  for  a  short  time  had 
no  especial  effect  on  guinea  pigs.  When,  however,  the  milk  was 
heated  for  a  long  time  at  a  high  temperature  the  guinea  pigs  died 
and  single  bones  showed  changes  which  Bolle  identified  as  scor- 
butus. Moore  and  Jackson  ^  found  that  when  guinea  pigs  were  fed 
on  hay  and  milk,  they  developed  scurvy  whether  the  milk  was 
given  raw,  pasteurized  or  boiled.  The  symptoms  appeared  most 
quickly  when  the  milk  was  given  raw.  Furthermore,  the  addition 
of  milk  to  an  otherwise  suitable  diet  caused  scurvy.  It  seems 
evident,  therefore,  that  no  conclusions  can  be  drawn  as  to  the 
effect  of  the  heating  of  milk  in  the  production  of  scurvy  in  man 
from  experiments  on  guinea  pigs. 

Experimental  Scorbutus  in  Animals. — Hoist  and  FroUch  were 
the  first  to  produce  scorbutus  in  animals,  in  1907.  They  and 
Fiirst  continued  their  work  for  some  years.^  Talbot  and  Peterson  * 
repeated  and  confirmed  their  experiments.  They  found  that  when 
guinea  pigs  were  fed  exclusively  on  various  forms  of  bread  and 

^  Plantanza:  Archiv.  f.  Kinderhielkunde,  1912,  Ivii,  155. 

*  Zeit.  f .  Hygiene  u.  Infectionskrankheiten,  1912,  Ixxii,  155. 

'  Bolle  and  Bartenstein:  quoted  by  Hart,  Virchow's  Archiv.  f.  path.  Anat. 
u.  Phys.,  1912,  ccviii,  367. 

*  Moore  and  Jackson:  Joum.  Amer.  Med.  Ass.,  1916,  Ijcvii,  1931. 

'^  Hoist  and  Frolich:  Journal  of  Hygiene,  Cambridge,  1907,  vii,  619;  Norsk 
Magazin  for  Laegevedenskaben,  1910,  Ixxi,  No.  3;  Zeit.  f.  Hygiene  u.  Infec- 
tionskrankheiten, 1912,  Ixxii,  Part  One;  Fiirst:  Norsk  Magazin  for  Laegeved- 
enskaben, 1912,  Ixxiii,  No.  1. 

*  Boston  Medical  and  Surgical  Journal,  1913,  clxix,  232. 


346  ETIOLOGY 

grain,  they  died  in  from  four  to  six  weeks  of  a  disease  which  in  its 
sjmaptoms  and  pathological  anatomy  corresponded  with  human 
scorbutus.  They  believed  that  the  sjonptoms  and  pathological 
changes  were  caused  by  the  diet.  Others  claimed,  however,  that 
they  were  the  result  of  inanition  from  starvation.  They  then  fed 
guinea  pigs  on  fresh  white  cabbage,  dandelions  or  carrots  in  such 
small  amounts  that  the  animals  lost  from  30%  to  40%  of  their 
weight.  None  of  these  animals  developed  scorbutus,  whereas  ani- 
mals that  were  fed  on  dried  grains  or  bread  and  lost  a  like  amount 
of  weight  or  relatively  a  few  grams,  showed  scorbutic  changes. 
These  experiments  proved  conclusively  that  the  scorbutic  changes 
were  not  due  to  simple  inanition.  It  is  interesting  to  note  in  this 
connection  that  there  are  records  of  cases  of  human  scorbutus 
which  followed  a  diet  which  was  the  same  or  similar  to  that  given 
to  the  guinea  pigs. 

They  found  that  scorbutus  in  guinea  pigs  is  reheved  or  cured  by 
fresh  vegetables  in  the  same  way  that  it  is  in  man.  The  anti- 
scorbutic properties  of  the  vegetables  are  usually,  if  not  always, 
weakened  by  the  process  of  cooking,  but  are  rarely  entirely  de- 
stroyed. There  seems  to  be  some  connection  between  the  in- 
tensity of  the  heat  used  in  cooking  and  the  loss  of  the  therapeutic 
properties.  For  example,  white  cabbages  are  of  less  therapeutic 
value  when  they  are  cooked  at  from  110°  C.  to  120"  C.  than  when 
they  are  boiled. 

The  fresh  vegetables  lose  their  antiscorbutic  properties  in  vary- 
ing degrees  when  they  are  dried.  Among  those  which  they  in- 
vestigated are  potatoes,  carrots,  dandelions  and  white  cabbage. 
These  vegetables  are  affected  differently  by  drying.  DandeUons 
lose  their  therapeutic  value  immediately  on  drying,  while  white 
cabbage  retains  it  longer  when  kept  in  an  open  vessel  in  an  incu- 
bator at  37°  C.  than  when  it  is  kept  at  room  temperature.  Freshly 
pressed  cabbage  juice  quickly  loses  its  antiscorbutic  proper- 
ties when  it  is  heated  at  from  60°  C.  to  100°  C.  for  ten  minutes. 
The  same  thing  happens  when  it  is  preserved  for  a  long  time  either 
at  room  temperature  or  in  an  ice  chest.  Pressed  dandeUon  juice 
also  loses  its  prophylactic  properties  when  heated  for  a  short  time. 

In  contradistinction  to  the  above,  lemon  juice  will  withstand  for 
a  long  time  the  same  heat  that  will  weaken  or  entirely  destroy  the 
virtue  of  white  cabbage  or  dandelion  juice.  Raspberry  juice  can 
be  cooked  for  one  hour  at  100°  C.  without  losing  any  of  its  anti- 
scorbutic properties.  Hoist  and  Frolich  thought  there  must  be 
some  connection  between  the  acidity  of  these  juices  and  their 
antiscorbutic  properties  and  they  were  able  to  increase  the  resist- 


ETIOLOGY  347 

ance  of  white  cabbage  and  dandelion  juice  to  heat  by  the  addition 
of  acids.  They  were  not  able  to  increase  this  resistance  so  that  it 
would  stand  prolonged  heating.  They  were  unable  to  determine 
the  nature  of  the  antiscorbutic  bodies  by  dialysis,  by  extraction  or 
other  experimental  methods. 

Fiirst  ^  found  that  the  feeding  of  guinea  pigs  exclusively  on  plant 
seeds  would  produce  scorbutus,  although  not  so  easily  and  regularly 
as  exclusively  grain  feeding.  Plant  seeds  that  produced  scur\^ 
acquired  antiscorbutic  properties  when  infected  with  fungi.  He 
concluded  from  his  experiments  that  neither  the  ash  nor  any  of  its 
alkaUs  plays  any  part  in  the  incidence  of  scorbutus.  There  was 
no  apparent  connection  between  the  fat,  alkali,  carbohydrate, 
cellulose  or  enzymes  in  the  food  and  the  appearance  of  the  disease. 

Hart  ^  was  able  to  produce  scorbutus,  characteristic  in  both  its 
symptoms  and  pathological  anatomy,  by  feeding  monkeys  ex- 
clusively on  trade  condensed  milk.  They  were  kept  in  such  good 
surroundings  that  they  did  not  become  rachitic.  Control  animals 
fed  on  a  mixed  diet  did  not  develop  scurvy.  His  results  were 
confirmed  by  Dodd.^ 

Heubner  and  Lippschultz  '*  fed  dogs  for  many  weeks  on  a  food 
poor  in  phosphorus  and  found  microscopic  changes  in  the  bones 
very  similar  to  those  found  in  scorbutus. 

Jackson  and  Moore  ^  corroborated  the  findings  of  other  observers 
that  inanition  does  not  produce  scurvy  and  found  further  that 
cow's  milk  in  any  form  not  only  does  not  cure  scurvy  in  guinea 
pigs  but  causes  it.  Goat's  milk,  however,  does  not  cause  it.  They 
also  determined  by  experiments  that  the  lactose  in  milk  is  not  the 
cause  of  scurvy  in  guinea  pigs  and  that  scurvy  is  not  due  to  a  lack 
of  lime  salts.  They  call  attention  to  the  facts  that  a  diet  which 
is  suflBcient  for  growth  and  maintenance  in  one  species  may  be  ade- 
quate for  another,  sufficient  for  maintenance  in  another  and  pro- 
duce one  of  the  deficiency  diseases  in  a  third,  and  that  conclusions 
based  on  dietary  experiments  on  one  species  of  animals  can  be 
applied  only  to  that  species. 

The  results  of  these  experiments  hardly  justify  any  very  positive 
conclusions  as  to  the  cause  of  scurvy.  They  show  very  definitely, 
however,  that  scurvy  is  not  due  to  starvation  and  that  it  is  not 

^  Zeit.  f.  Hyg.  u.  Infectionskrankheiten,  1912,  Ixxii,  121. 

*  Hart:  Virchow's  Archiv.  f.  path.  Anat.  u.  Phys.,  1912,  ccviii,  367. 
»  Dodd:  Boston  Medical  and  Surgical  Journal,  1913,  clxix,  237. 

*  Huebner  and  Lippschultz,  quoted  by  Hart:  Virchow's  Arch.  f.  path.  Anat. 
u.  Phys.,  1912,  ccviii,  367. 

'  Jackson  and  Moore:  Joum.  Infect.  Dis.,  1916,  xix,  478;  and  Joum.  Amer. 
Med.  Ass.,  1916,  Ixvii,  1931. 


348  METABOLISM  IN  SCURVY 

brought  on  simply  by  the  long-continued  use  of  a  single  article  of 
food.  They  suggest  very  strongly  that  when  scurvy  develops  as 
the  result  of  the  continuous  use  of  a  single  food,  the  trouble  with 
the  food  is  not  that  it  contains  some  substance  which  causes  scurvy 
but  that  it  lacks  some  substance  which  prevents  scurvy.  They 
also  seem  to  show  that  this  substance  which  prevents  scurvy  is 
partially  or  wholly  destroyed  by  drying  and  heating.  They  do  not 
show  whether  this  hj^^othetical  substance  is  a  single  definite  en- 
tity or  a  group  of  substances,  closely  related  to  each  other  and 
similar  in  their  action. 

The  Metabolism  in  Scorbutus. — ^Very  little  is  known  as  to  the 
metabohsm  in  scurvy.  The  only  accurate  study  on  the  metabolism 
of  scorbutus  in  adults  is  that  of  Baumann  and  Howard  ^  who  found 
that  the  loss  of  the  various  food  constituents  through  the  feces  was 
less  when  fruit  juice  was  added  to  the  diet.  The  total  sulphur 
metabolism  was  abnormal  throughout  the  experiment,  the  quantity 
eliminated  being  in  excess  of  that  ingested.  Chlorine  and  sodium 
were  retained  during  the  fruit  juice  period,  but  were  excreted  in 
excess  of  the  intake  during  the  preliminary  period.  More  potas- 
sium, calcium  and  magnesium  were  retained  during  the  fruit 
juice  period  than  during  the  preliminary  period.  Lusk  and  Kloc- 
man  ^  studied  the  metabohsm  of  nitrogen  and  the  mineral  salts  in 
a  typical  case  of  scurvy  in  an  infant  eighteen  months  old.  Obser- 
vations were  made  for  three  periods  of  four  days  each;  the  first 
while  the  disease  was  at  its  height  and  the  child  was  not  being 
treated;  the  second,  after  a  month's  treatment;  and  the  third,  a 
month  later,  after  all  symptoms  had  disappeared.  The  nitrogen 
balance  was  normal  at  all  times.  The  balance  of  mineral  salts, 
particularly  of  calcium,  was  somewhat  increased  in  the  first  period; 
in  the  second  period  during  convalescence  it  was  markedly  de- 
creased; and  in  the  third  period  was  approaching,  but  had  not 
reached,  the  normal,  although  the  child  was  clinically  well.  This 
is  in  decided  contrast  to  the  condition  in  rickets.  Bahrdt  &  Edel- 
stein  ^  obtained  very  different  results  from  their  analysis  of  the 
organs  of  an  eight  months'  old  baby  dead  of  scurvy,  which  showed 
no  signs  of  rickets.  The  ash  of  the  bones  was  much  less  than  nor- 
mal. They  contained  only  from  1/5  to  1/3  of  the  normal  amount 
of  calcium  and  there  was  a  corresponding  diminution  in  the  phos- 
phorus. The  sodium  and  potassium  were  somewhat  increased. 
There  was  also  a  diminution  in  the  calcium  in  the  muscles.    The 

^  Baumann  and  Howard:  Archives  of  Internal  Medicine,  1912,  ix,  665. 

^  Lusk  and  Klocman:  Jahrb.  f.  Kinderheilkunde,  1912,  Ixxv,  663. 

3  Bahrdt  &  Edelstein:  Ztschr.f.  Kiiiderheilk,  1913,  ix,  415  and  1914,  x,  352. 


VITAMINS  349 

amount  of  salts  in  the  other  organs  was  apparently  normal.  These 
studies,  while  interesting,  show  nothing,  however,  as  to  the  etiology 
of  this  disease. 

The  Vitamins. — Funk  has  recently  called  attention  to  the  sig- 
nificance of  the  so-called  vitamins  in  physiology  and  pathology, 
especially  in  relation  to  the  etiology  of  what  he  calls  the  "avita- 
minoses,"  namely,  beriberi,  scorbutus,  pellagra  and  rickets.^ 
He  believes,  and  advances  strong  evidence  to  prove,  that  these 
diseases  are  due  to  the  absence  of  certain  vital  substances  in  the 
food,  that  is,  the  vitamins.  He  shows  from  this  own  work  and 
that  of  others  that  milk  contains  a  considerable  number  of  these 
antiscorbutic  substances  as  well  as  a  substance  which  materially 
favors  the  growth  of  young  animals.  The  development  of  scurvy 
in  infants  taking  foods  which  contain  no  milk  may  be  explained, 
therefore,  by  assuming  that  these  foods  do  not  contain  the  essen- 
tial vitamins  which  milk  does  contain.  The  vitamins  are,  in 
general,  very  sensitive  to  heat.  Those  in  milk  are  relatively  stable. 
They  are,  however,  partially  destroyed  by  heating  milk  for  a  short 
time,  and  totally  destroyed  by  long  heating  or  sterilization.  The 
development  of  scurvy  in  babies  taking  heated  milk  and  the 
greater  frequency  of  the  disease  when  the  food  is  boiled  or  steriUzed 
than  when  it  is  pasteurized  may  be  explained  by  assuming  that  the 
vitamins  are  partially  or  wholly  destroyed  by  the  heating,  the 
destruction  being  more  or  less  complete  according  to  the  degree 
and  duration  of  the  heating.  Scurvy  sometimes  develops,  however, 
in  babies  that  are  taking  raw  milk,  or  even  in  those  that  are  on 
the  breast.  His  explanation  of  the  development  of  s^curvy  on  a 
diet  of  raw  milk  is  that  in  such  instances  the  milk  is  deficient  in 
vitamins.  In  support  of  this  explanation  he  brings  forward  evi- 
dence to  show  that  the  amount  of  the  vitamins  in  the  milk  varies 
with  the  amount  of  the  vitamins  in  the  food  of  the  cows.  An 
example  of  the  influence  of  the  food  of  the  cows  upon  the  amount 
of  vitamins  in  the  milk  is  the  fact  that  their  milk  contains  less 
vitamins  in  the  winter,  when  they  are  eating  dry  food,  than  in 
the  summer,  when  they  are  eating  green  food.  The  develop- 
ment of  scurvy  in  infants  on  the  breast  may  be  explained  in  a 
similar  way.  He  calls  attention  to  the  fact,  moreover,  that 
the  vitamins  are  diminished  in  the  milk  of  women  who  are 
imderfed. 

Many  objections  can  be  raised  to  Funk's  arguments  and  it  may 
be  urged  that  his  premises  are  incorrect  and  his  conclusions  con- 

*  Casimir  Funk.  Die  Vitamine,  etc.,  Wiesbaden:  J.  F.  Bergman,  1914. 


350  VITAMINS 

sequently  not  justified.  Nevertheless,  his  proposition  that  scurvy- 
is  caused  by  the  diminution  or  absence  of  certain  essential  vital 
elements,  or  vitamins,  in  the  food,  reconciles  and  explains  the 
clinical  facts  and  experimental  evidence  as  to  the  etiology  of  this 
disease  better  than  any  other  which  has  been  advanced. 

Hess  *  calls  attention  to  the  fact  that  enlargement  of  the  heart, 
edema  and  nerve  degeneration,  which  occur  in  scurvy,  are  per- 
manent symptoms  in  beriberi,  which  is  without  question  a  de- 
ficiency disease,  and  considers  it  a  strong  argument  that  scurvy 
is  also  a  member  of  this  group.  The  improvement  of  babies  with 
scurvy  when  wheat  middlings  are  added  to  the  diet  he  considers 
further  proof. 

McCoUum  and  Davis  ^  concluded  from  their  studies  of  rats  which 
failed  to  grow  and  live  on  diets  composed  of  purified  food  ele- 
ments that  there  were  lacking  in  such  food  mixtures  two  essential 
substances,  or  groups  of  substances.  McCoUum  and  Kennedy  ' 
think  that  the  term  vitamins  does  not  adequately  describe  these 
substances  and  prefer  the  terms  "fat-soluble  A"  and  "water- 
soluble  B"  for  them.  The  first  is  found  in  abundance  in  butter- 
fat  and  egg-fat  and  the  latter  in  the  leaves  of  plants,  but  only  to  a 
small  amount  in  their  seeds. 

McCoUum  and  Pitz  ^  found,  as  did  Jackson  and  Moore,^  that  the 
addition  of  milk  to  a  diet  of  oats  did  not  prevent  the  development 
of  scurvy  in  guinea  pigs,  and  conclude,  therefore,  that  the  lack  of 
"fat-soluble  A"  cannot  be  the  cause  of  scurvy.  They  also  con- 
clude from  a  series  of  experiments  on  rats  that  the  "water-soluble 
B"  must  have  been  present  in  the  oats.  Therefore,  they  beheve 
that  scurvy  in  the  guinea  pig  cannot  be  due  to  a  lack  of  any  specific 
substance  of  this  class.  Consequently  they  conclude  that  scurvy 
is  not  a  deficiency  disease  in  the  sense  in  which  the  term  has  re- 
cently been  used. 

They  found  in  guinea  pigs  which  died  of  scurvy  on  a  diet  of 
oats  and  milk,  the  stomach,  small  intestines  and  lower  colon  were 
empty  while  the  cecum  was  distended  with  putrefying  feces.  The 
cecum  of  the  guinea  pig  is  very  large  and  delicate.  They  argue, 
therefore,  as  follows:  The  guinea  pig  can  thrive  only  on  a  diet  which 
leads  to  the  formation  of  bulky  and  easily  eliminable  feces.    Diets 

^  Hess:  Journ.  Amer.  Med.  Ass.,  1915,  Ixv,  1003. 

*  McCoUum  and  Davis:  Journ.  Biol.  Chem.,  1915,  xxiii,  181. 
'  McCollum  and  Kennedy:  Journ.  Biol.  Chem.  xxiv,  491. 

*  McCollum  and  Pitz:  Journ.  Biol.  Chem.  1917,  xxxi,  229. 

*  Jackson  and  Moore:  Journ.  Infect.  Dis.,  1916,  xix,  478,  and  Journ.  Amer. 
Med.  Ass.,  1916,  Ixvii,  1931. 


TREATMENT  351 

such  as  oats  do  harm  only  in  that  they  form  pasty  feces  which 
cannot  be  passed  out  of  the  delicate  cecum.  Putrefaction  occurs, 
which  injures  the  cecal  wall,  which  allows  the  passage  of  bacteria 
or  toxins,  which  by  their  action  on  the  walls  of  the  capillaries 
produce  the  characteristic  symptoms  of  scurvy.  They  found 
further  that  the  addition  of  laxatives  to  the  food  which  produced 
scurvy  prevented  or  delayed  its  development.  They  believe  that 
orange  juice  does  good  simply  because  of  its  laxative  action.  They 
do  not  go  so  far  as  to  claim  that  the  cause  of  scurvy  in  infancy  is 
colonic  stasis  with  the  absorption  of  toxins  or  bacteria,  but  think 
that  their  experiments  lend  support  to  this  belief.  The  chief 
objections  to  their  arguments  are  that  conclusions  based  on  dietary 
experiments  in  one  species  of  animals  cannot  be  apphed  to  others 
or  those  on  animals  to  man,  that  the  infantile  cecum  is  not  especially 
large  or  delicate  and  that  laxatives  do  not  cure  scurvy  in  infants. 

TREATMENT 

There  is  nothing  in  the  pathological  changes,  in  the  causes 
underlying  the  hemorrhagic  condition,  or  in  the  results  obtained 
from  studies  of  the  metabolism  in  this  disease  which  yields  any 
information  of  value  as  to  its  treatment.  The  clinical  and  experi- 
mental evidence  all  goes  to  show,  however,  that  the  disease  is 
due  to  the  lack  of  some  essential  element  or  elements  in  the  food, 
probably  belonging  to  the  class  of  vitamins.  This  same  evidence 
also  shows  that  these  elements  are  likely  to  be  deficient  in  foods 
which  do  not  contain  milk.  It  shows,  too,  that  they  are  present  in 
milk  and  that  they  are  weakened  or  destroyed  when  milk  is  heated, 
the  effect  of  the  heating  apparently  depending  on  the  degree  of 
heat  and  the  duration  of  the  heating.  They  are  almost  invariably 
present  in  sufficient  quantities  in  human  milk. 

The  indications  furnished  by  this  evidence  as  to  the  preventive 
treatment  of  scurvy  are  obvious.  Babies  should  be  nursed,  when- 
ever this  is  in  any  way  possible.  If  the  supply  of  breast-milk  is 
insufficient,  they  should  be  given  all  that  there  is  in  order  to  make 
up  for  any  possible  deficiency  in  the  antiscorbutic  elements  in  the 
artificial  food.  If  it  is  necessary  to  use  an  artificial  food,  the  basis 
of  this  food  should  be  milk,  which  contains  antiscorbutic  elements. 
Unless  the  use  of  raw  milk  is  for  some  reason  contraindicated,  the 
milk  should  be  given  raw,  because  heating  milk  almost  certainly 
weakens  its  antiscorbutic  properties.  If  it  is  necessary  to  heat  the 
liiilk,  it  should  be  pasteurized  at  the  lowest  temperature  con- 
sistent with  safety,  in  order  that  these  properties  may  be  weakened 


352  TREATMENT 

as  little  as  possible.  If  it  is  necessary  to  use  heated  milk  con- 
tinuously, antiscorbutics  should  be  given  in  addition.  Babies 
should  not  be  given  foods  for  any  considerable  length  of  time 
which  do  not  contain  milk. 

It  has  been  known  for  many  years  that  fresh  vegetables  and 
fruits  contain  elements  which  cure  scurvy.  The  antiscorbutic 
properties  of  fruits  are  in  general  greater  than  those  of  vegetables. 
These  properties  are  present  in  the  fruit  juices.  Fruit  juices  can 
be  easily  given  to  babies;  vegetable  and  vegetable  juices  are  less 
suitable  for  them.  The  most  available  fruit  juices  are  those  of 
the  lemon  and  orange.  Babies  prefer  the  taste  of  orange  juice  to 
that  of  lemon  juice  and  it  is  less  likely  to  disturb  the  digestion. 
Orange  juice  should  be  used,  therefore,  in  the  treatment  of  scurvy, 
if  it  is  easily  procurable.  It  should  be  given  in  doses  of  one  ounce 
daily.  Less  than  this  amount  is  liable  to  be  ineffective,  and  ex- 
perience has  shown  that  more  than  this  is  unnecessary.  It  is 
best  given  in  one  dose,  one  hour  before  a  feeding,  when  the  stomach 
contains  but  little  milk.  It  is  less  likely  to  disturb  the  digestion  if 
given  in  this  way.  There  is  no  objection  to  diluting  it  with  water 
or  to  adding  cane  sugar  to  it,  if  the  babies  object  to  it  plain.  The 
boiling  of  orange  juice  does  not  lessen  its  therapeutic  value.  It 
does  not,  however,  increase  it.  There  is,  therefore,  no  object  in 
boihng  it.  The  juice  of  the  orange  peel  also  contains  antiscorbutic 
elements.^  The  only  reason  for  using  it  instead  of  orange  juice 
is  for  the  sake  of  economy. 

Since  orange  juice  and  lemon  juice  are  so  easily  procurable,  and 
since  they  are  probably  the  most  powerful  antiscorbutics,  it  hardly 
seems  necessary  to  consider  vegetables  and  other  fruits,  even 
though  they  also  will  cure  scurvy.  An  exception  may  perhaps 
be  made  in  the  case  of  potato,  which  is  easily  procured  and  inexpen- 
sive. The  potato  should  be  boiled  and  mashed  and  given  in  doses 
of  at  least  a  tablespoonful  daily.  Hess  and  Fish  ^  have  suggested 
the  use  of  potato  water,  made  by  mixing  one  tablespoonful  of 
boiled  and  mashed  potato  in  a  pint  of  water,  instead  of  the  cereal 
waters  in  the  preparation  of  foods  for  infants  as  a  preventive  of 
scurvy.  Hess  ^  found  that  wheat  germ  and  wheat  middlings  did  not 
have  enough  antiscorbutic  power  to  make  them  of  value  from 
either  a  practical  or  clinical  standpoint.  There  is  no  apparent  ad- 
vantage in  the  use  of  alcoholic  extracts  of  vegetables,  as  suggested 

^  Hess  and  Fish:  Amer.  Jour.  Dis.  of  Children,  1914,  viii,  385. 
*  Loc.  cit. 

■'  Hess:  Journ.  Amer.  Med.  Ass.,  1915,  Ixv,  1003  and  Amer.  Joum.  Dis.  of 
Ch.,  1917,  xiii,  98. 


TREATMENT  353 

by  Freise,^  even  if  they  will  cure  scurvy,  when  fruit  juices  are  so 
easily  procurable. 

Scurvy  can  also  be  cured  by  a  change  in  the  character  of  the  food. 
Human  milk  will  cure  scurvy.  The  substitution  of  a  food  con- 
taining milk  for  one  which  does  not  or  stopping  the  heating  of 
the  milk  will  usually  cure  it.  Recovery  is  slow  under  these  cir- 
cumstances, however,  while  it  is  very  rapid  when  orange  juice  is 
given.  It  is  inadvisable,  therefore,  to  trust  to  a  change  in  the  food 
to  cure  the  disease.  Orange  juice  will  cure  it,  even  if  the  food 
which  caused  the  scurvy  is  continued.  It  is  wiser,  however,  to 
change  the  food  unless  there  is  some  special  reason  in  connection 
with  the  baby's  digestive  capacity  for  continuing  it. 

Cod-liver  oil  and  olive  oil  do  not  either  prevent  or  cure  scurvy. 

Yeast,  whether  autolyzed  or  dessicated,  has  no  value  either  as  a 
prophylactic  or  curative  agent.  ^  There  are  no  drugs  which  have 
any  influence  upon  it. 

*  Freise:  Monatschr.  f.  Kinderheilk.,  1914,  xii,  687. 
2  Hess:  Amer.  Journ.  Dis.  of  Ch.  1917,  xiii,  98. 


CHAPTER  XXrX 
SPASMOPHILIA 

Spasmophilia  is  a  constitutional  anomaly  which  presents  and  is 
recognizable  by  a  characteristic  mechanical  and  electrical  overex- 
citability  of  the  nervous  system  and  which  produces  a  pathologic 
predisposition  to  certain  partial  and  general  clonic  and  tonic  con- 
vulsions.^ Its  most  familiar  manifestations  are  tetany,  laryn- 
gismus stridulus  and  convulsions.  The  best  known  signs  of  the 
increased  mechanical  overexcitability  of  the  nervous  system  are 
Trousseau's  sign  and  Chvostek's  sign,  or  the  facial  phenomenon. 
Erb's  sign  is  the  name  given  to  the  peculiar  quantitative  reaction 
of  the  nerves  to  the  galvanic  current.  Thiemich  and  Mann  ^ 
worked  out  a  typical  law  of  contraction  for  this  condition  a  number 
of  years  ago.  For  practical  purposes,  however,  it  is  sufficient  to 
remember  that  the  appearance  of  cathodal  opening  contractions 
under  5  ma  is  pathognomonic  of  spasmophilia  and  that  the  ap- 
pearance of  anodal  opening  contractions  with  less  current  than 
that  causing  anodal  closing  contractions  is  very  strong  evidence 
in  favor  of  it. 

Pathological  Anatomy. — There  are  no  characteristic  patholo- 
gical lesions  in  spasmophilia.  Various  lesions  of  the  parathyroids 
have  been  found  in  some  instances,  but  it  is  very  doubtful  if  these 
lesions  have  any  direct  connection  with  the  disease. 

Etiology. — Much  has  been  written  in  recent  years  as  to  the  eti- 
ology of  spasmophilia,  but  as  yet  no  absolutely  positive  conclusions 
are  justified.  The  best  summaries  of  the  literature  of  the  subject 
in  English  are  to  be  found  in  the  articles  of  Reye,  Brown  and 
Fletcher,  Gamble  and  Grulee.^ 

Heredity. — It  has  long  been  recognized  that  spasmophilia  is  often 
hereditary  or  familial  in  type.^  It  is  self-evident,  however,  that 
heredity  is  not  the  chief  factor  in  the  causation  of  this  condition, 

^  Pfaundler  and  Schlossmann:  The  Diseases  of  Children,  1908,  iv,  289. 
2  Thiemich  and  Mann:  Jahrb.  f.  Kinderh.,  1900,  li,  99  and  222. 

*  Reye:  Archives  of  Pediatrics,  1914,  xxxi,  664;  Brown  and  Fletcher:  Amer. 
Journ.  Dis.  Child.,  1915,  x,  313;  Gamble:  Amer.  Journ.  Dis.  Child.,  1917,  xiii, 
384;  and  Grulee:  Amer.  Journ.  Dis.  Child.,  1917,  xiii,  44. 

*  Thiemich  in  Pfaundler  and  Schlossmann:  The  Diseases  of  Children,  1908, 
iv,  285;  Schiffer:  Jahrb.  f.  Kinderh.,  1911,  Ixxiii,  601;  Sedgwick:  Amer.  Journ. 
Dis.  Child.,  1914,  vii,  140. 

354 


CALCIUM  METABOLISM  355 

because  in  the  vast  majority  of  cases  there  is  no  evidence  of  hered- 
ity. Moreover,  when  it  occurs  in  several  members  of  the  same 
family,  environment  affords  as  good  an  explanation  of  its  occurrence 
as  heredity.  Furthermore,  a  neuropathic  family  history  is  lacking 
in  a  majority  of  the  cases.  In  cases  in  which  there  is  a  neuropathic 
family  history,  it  is  possible  that  a  nervous  system  of  low  resistance 
may  have  been  transmitted  and  predispose  to  the  development  of 
this  condition.  It  is  certain  that  heredity  can  play  no  larger  part 
than  this  in  its  etiology. 

Calcium  Metabolism. — Most  of  those  who  have  made  a  study  of 
spasmophilia  in  recent  years  connect  it  with  a  disturbance  of  the 
calcium  metabolism,  the  great  majority  believing  that  it  is  due  to 
a  deficiency  of  calcium  in  the  tissues.  Stoeltzner  ^  thought  from 
his  experiments  that  spasmophilia  was  due  to  an  increase  in  the  cal- 
cium content  of  the  tissues.  His  results  were,  however,  quickly  dis- 
proved by  Riesel.^  No  one  has  found  an  increase  in  the  calcium  re- 
tention in  this  disease.  On  the  other  hand,  experiments  have  failed 
to  show  that  there  is  constantly  a  diminished  or  negative  calcium 
balance.^ 

Quest,  ^  however,  found  that  the  calcium  content  of  the  brains  of 
two  infants  dead  of  spasmophilia  was  considerably  lower  than  that 
of  the  brain  of  a  normal  infant.  Aschenheim  ^  confirmed  his  findings 
but  Cohn  ^  did  not.  MacCallum  and  Voegtlin  ^  also  found  a  dim- 
inution in  the  amount  of  calcium  in  the  brain  and  spinal  cord  of 
dogs  with  experimental  parathyroid  tetany.  Katzenellenbogen  ^ 
found  a  diminution  in  the  calcium  of  the  blood  in  four  out  of  five 
infants  with  spasmophilia,  while  Rowland  and  Marriott,'  using  a 
new  and  accurate  method  of  their  own,  found  that  the  calcium 
content  in  spasmophilia  was  regularly  low.  They  also  found  a  dim- 
inution in  the  calcium  content  of  the  blood  of  dogs  ill  with  ex- 
perimental tetany  after  parathjo-oidectomy.  So  also  did  MacCal- 
lum and  Vogel.^" 

1  Stoeltzner:  Jahrb.  f.  Kinderh.,  1906,  bdii,  661. 

«  Riesel:  Archiv.  f.  Kinderh.,  1908,  xlviii,  165. 

'Cybulski:  Monatschr.  f .  Kinderh.,  1906,  v,  409;  Schabad:  Monatschr.  f. 
Kinderh.,  1910,  ix,  25;  Schwartz  and  Bass:  Amer.  Joum.  Dis.  Child.,  1912,  iii, 
15. 

*  Quest:  Jahrb.  f.  Kinderh.,  1905,  bd,  114  and  Wien.  kUn.  Woch.,  1906,  xix, 
830. 

*  Aschenheim:  Monatschr.  f.  Kinderh.,  1910,  ix,  366. 
6  Cohn:  Deutsch.  Med.  Woch.,  1907,  xxxiii,  1987. 

^  MacCallum  and  VoegtHn:  Joum.  Exp.  Med.,  1909,  xi,  118. 

*  Katzenellenbogen:  Ztschr.  f.  Kinderh.,  1913,  viii,  187. 

^  Rowland  and  Marriott:  Trans.  Amer.  Ped.  Soc,  1916,  xxviii,  200. 
w  MacCallum  and  Vogel:  Journ.  Exp.  Med.,  1913,  xviii,  618. 


356  CALCIUM  METABOLISM 

Rosenstem  *  was  able  to  reduce  the  electrical  excitability  in  in- 
fants with  spasmophilia  by  giving  large  amounts  of  calcium  salts 
by  mouth.  Zybell  ^  was  also  able  to  reduce  the  electrical  excita- 
bility by  giving  large  amounts  of  calcium  salts,  but  thought  that 
the  results  from  small  doses  were  inconclusive. 

It  is  generally  believed  that  calcium  and  magnesium  salts  tend 
to  lower  nervous  irritability  and  that  sodium  and  potassium  salts 
tend  to  increase  it.  That  is,  these  salts  act  antagonistically  to  each 
other.  Reiss  ^  has  expressed  this  proposition  by  the  following  for- 
mula: -r^T^ — r—TT-  Spasmophilia  can  thus  be  explained  by  a  dim- 
Na+  K 

inution  in  the  calcium  and  magnesium  salts  in  the  tissues.  The 
data  just  given  are  evidence  in  favor  of  this  explanation,  as  far  as 
regards  calcium.  There  are  practically  no  data  as  to  magnesium. 
Theoretically  spasmophilia  might  equally  well  be  due  to  an  in- 
crease in  the  sodium  and  potassium  salts  in  the  tissues.  Aschen- 
heim  ^  found  an  absolute  increase  of  these  salts  in  the  brain  tissue 
of  infants  dead  of  spasmophilia,  as  well  as  a. diminution  in  the  cal- 
cium. Zybell  ^  was  able  to  increase  the  electrical  excitability  in  spas- 
mophilia by  giving  large  doses  of  acetate  of  potash  and  Rosenstern  ^ 
by  large  doses  of  sodium  chloride,  while  MacCallum  and  Voegtlein  ^ 
were  able  to  increase  the  severity  of  the  symptoms  of  tetany  in  para- 
thyroidectomized  animals  by  the  injection  of  sodium  and  potas- 
sium salts.  Lust  ^  described  a  case  of  tetany  in  an  infant  of  two 
years  in  which  there  was  also  marked  edema.  The  symptoms  of 
tetany  disappeared  and  reappeared  coincidently  with  the  dis- 
appearance and  reappearance  of  the  edema.  He  concluded  from 
this  observation  that  the  spasmophilia  was  due  to  an  increase  in 
the  sodium  chloride  retention.  Brown  and  Fletcher^  have  called 
attention  to  the  improvement  in  the  symptoms  of  spasmophilia 
when  diarrhea  occurs  and  attribute  it  to  the  loss  of  sodium  and  po- 
tassium in  the  stools.  They  quote  in  favor  of  this  view  the  obser- 
vation of  Holt,  Courtney  and  Fales  ^°  who  found  that  there  was  a 

^  Rosenstern:  Jahrb.  f.  Kinderh.,  1910,  Ixxii,  154. 
2  ZybeU:  Jahrb.  f.  Kinderh.,  1913,  Ixxviii,  29. 
'  Reiss:  Ztschr.  f.  Kinderh.,  1911,  iii,  1. 

*  Aschenheim:  Jahrb.  f.  Kinderh.,  1914,  bodx,  446. 
6  ZybeU:  Jahrb.  f.  Kinderh.,  1913,  kviii.  29. 

^  Rosenstern:  Jahrb.  f.  Kinderh.,  1910,  Ixxii,  154. 

^  MacCallum  and  Voegtlein:  Journ.  Exp.  Med.,  1909,  xi,  118. 

« Lust:  Munchen.  Med.  Woch.,  1913,  vi,  93. 

•  Brown  and  Fletcher:  Amer.  Journ.  Dis.  Children,  1916,  x,  313. 

"Holt,  Courtney  and  Fales:  Amer.  Journ.  Dis.  Children,  1915,  ix, 
213. 


THE  PARATHYROIDS  357 

much  greater  loss  of  sodium  and  potassium  than  of  calcium  and 
magnesium  in  diarrheal  stools.  They  believe  that  spasmophilia  is 
due  to  an  increased  retention  of  sodium  and  potassium  in  the  tis- 
sues as  the  result  of  water  retention  on  improper  foods  and  of  con- 
stipation, and  present  their  study  of  one  case  in  favor  of  their 
belief.  Grulee  ^  concludes  from  his  studies  that  there  is  strong  evi- 
dence of  a  definite  relation  between  increased  electrical  irritability 
and  the  retention  of  sodium  and  potassium  salts,  but  does  not  think 
that  the  action  of  the  sodium  and  potassium  salts  is  due  primarily 
to  retention  of  water  in  the  system. 

Parathjrroids. — It  is  a  well-known  fact  that  tetany  can  be  pro- 
duced experimentally  in  dogs  by  extirpation  of  the  parathyroids. 
Tetany  also  develops  in  man  after  operations  for  goitre,  if  the 
parathyroids  are  not  saved.  As  soon  as  these  facts  were  noticed 
many  writers  at  once  attempted  to  prove  that  experimental  para- 
thyroid tetany  was  the  same  condition  as  postoperative  human 
tetany  and  that  both  were  identical  with  spontaneous  human  tet- 
any.2  It  was  a  logical  sequence  to  conclude  that  spasmophiUa 
was  due  to  insufficiency  of  the  parathyroids.  Efforts  were  then 
made  to  determine  if  there  was  any  pathologic  or  anatomic  evi- 
dence for  or  against  this  conclusion.  Thiemich^  found  nothing 
abnormal  in  the  parathyroids  of  three  spasmophilic  and  five  nor- 
mal infants.  Erdheim  *  and  others  found  that  hemorrhages  not 
infrequently  occurred  in  the  parathyroids  during  birth  as  the  re- 
sult of  asphj^ia.  Yanase  ^  found  the  parathyroids  normal  in  thir- 
teen infants  who  during  life  showed  normal  electrical  reactions, 
while  twelve  of  twenty-two,  or  54.5%,  who  showed  an  increase  in 
electrical  excitability  had  hemorrhages  in  the  parathyroids.  He 
believed,  therefore,  that  the  hemorrhages  interfered  with  the  fimc- 
tions  of  the  parathyroids  and  that  this  interference  resulted  in 
spasmophilia.  Others,  however,  notably  Auerbach,^  found  evi- 
dences of  hemorrhages  in  the  parathyroids  of  two-thirds  of  the 
children  with  normal  irritability.  They  concluded,  therefore,  that 
the  anatomical  evidence  in  favor  of  a  connection  between  the  para- 
thyroids and  spasmophilia  was  unconvincing.  Haberfeld^  and 
others  think  that  spasmophilia  is  not  due  to  changes  in  the  para- 
thyroids caused  by  hemorrhages  at  birth,  but  to  disturbance  of 

*  Grulee:  Amer.  Journ.  Dis.  Children,  1917,  xiii,  44. 
^  Reye:  Archives  of  Pediatrics,  1914,  xxxi,  664. 

»  Thiemich:  Jahrb.  f.  Kinderh.,  1900,  li,  99,  222. 

«  Erdheim:  Mitt.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1906,  xvi,  632. 

6  Yanase:  Jahrb.  f.  Kinderh.,  1908,  Ixvii,  57. 

*  Auerbach:  Jahrb.  f.  Kinderh.,  1911,  Ixxiii,  Supp.  193. 
">  Haberfeld:  Wien.  Med.  Woch.,  1910,  Ix,  2691. 


358  THE  PARATHYROIDS 

their  function.  It  is  obvious  that  it  is  difficult  to  prove  or  dis- 
prove this  assumption. 

On  the  chemical  side  MacCallum  and  Voegtlein  ^  found  a  dimi- 
nution in  the  calcium  in  the  blood  and  brains  of  parathyroidectom- 
ized  dogs.  Howland  and  Marriott  ^  also  found  a  diminution  in  the 
calcium  content  of  the  blood  of  parathyroidectomized  dogs.  Mac- 
Callum, Lambert  and  Vogel  ^  have  recently  shown  indirectly,  by 
the  use  of  the  dialysis  method  of  Abel,  Rowntree  and  Turner,  that 
there  is  a  diminution  in  the  calcium  content  of  the  blood  in  para- 
thyroidectomized dogs.  These  findings  suggest  strongly  that,  if 
it  is  accepted  that  spasmophilia  is  caused  by  a  diminution  in  the 
amount  of  calcium  in  the  tissues,  the  disturbance  of  the  calcium 
metabolism  is  due  to  an  insufficiency  of  the  parathyroids.  Wilson 
and  his  co-workers  ^  have  recently  shown  that  a  disturbance  of 
the  acid-base  balance  in  the  body  develops  after  parathyroid- 
ectomy in  dogs,  which  results  in  a  change  toward  alkalinity. 

It  is  evident  from  the  foregoing  review  of  the  literature  that 
the  evidence  is  conflicting  and  that  it  is  impossible  at  present  to 
draw  any  positive  conclusions  as  to  the  etiology  of  spasmophilia. 
It  seems  almost  certain,  however,  that  the  increased  nervous 
irritability  in  this  condition  is  due  either  to  a  diminution  of  the 
salts  of  calcium  and  magnesium  in  the  tissues  or  to  .an  excess  of 
the  salts  of  sodium  and  potassium.  It  seems  more  probable  that 
it  is  due  to  a  diminution  of  the  salts  of  calcium  and  magnesium 
than  to  an  increase  in  those  of  sodium  and  potassium.  If  it  is 
due  to  a  diminution  in  the  salts  of  calcium  and  magnesium,  it  is 
possible  that  the  diminution  in  these  salts  is  connected  in  some 
way  with  a  disturbance  of  the  functions  of  the  parathyroids. 

Treatment. — Clinically  the  symptoms  of  spasmophilia  in  in- 
fancy almost  invariably  disappear  promptly  when  the  babies  are 
put  on  human  milk.  In  the  very  rare  instances  in  which  they 
develop  in  babies  that  are  on  the  breast,  they  are  likely  to  dis- 
appear if  the  baby  is  given  another  breast-milk.  If  it  is  impossible 
to  give  breast-milk,  the  bowels  should  be  thoroughly  cleaned  out, 
as  this  may  perhaps  do  good  by  eliminating  the  salts  of  sodium 
and  potassium.  The  food  should  be  changed  to  one  made  up  of 
carbohydrates.    The  basis  of  this  food  should  be  one  of  the  cereal 

^  MacCallum  and  Voegtlein:  Joum.  Exp.  Med.,  1909,  xi,  118. 

2  Howland  and  Marriott:  Trans.  Amer.  Ped.  Soc,  1916,  xxviii,  200. 

*  MacCallum,  Lambert  and  Vogol:  Journ.  Exp.  Med.,  1914,  xx,  149. 

^Wilson,  Stearns  and  Thurlow:  Journ.  Biol.  Chem.,  1915,  xxiii,  89  and 
Wilson,  Stearns  and  Janney:  Journ.  Biol.  Chem.,  1915,  xxi,  169  and  1915,. 
xxiii,  123. 


TREATMENT  359 

waters  to  which  any  one  of  the  disaccharides  may  be  added.  Whey 
is  distinctly  contraindicated,  because  of  the  large  amount  of  salts 
which  it  contains.  It  is  inadvisable  to  keep  a  baby  on  such  a 
strictly  carbohydrate  diet  more  than  a  week  at  the  outside  and 
some  form  of  milk  must  be  added.  The  protein  is  best  added  in 
the  form  of  precipitated  casein  and  the  fat  in  the  form  of  high 
percentage  creams,  in  order  to  avoid  the  salts  in  the  whey.  Modi- 
fied protein-milk  is  often  useful.  No  artificial  food  can,  however, 
take  the  place  of  human  milk  in  this  condition.  Without  it,  re- 
covery is  always  slow  and  relapses  frequent. 

Phosphorus  and  cod-Uver  oil  are  highly  recommended  by  many 
authors  because  of  the  supposedly  favorable  influence  of  this 
combination  in  the  retention  of  calcium  and  because  of  the  prob- 
abiUty  that  spasmophiUa  is  due  to  a  lack  of  calcium  in  the  tissues. 
The  results  reported  by  those  who  have  used  this  method  of  treat- 
ment are,  however,  conflicting  and  there  is  considerable  doubt, 
moreover,  as  to  whether  phosphorus  and  cod-Hver  oil  really  do 
increase  the  retention  of  calcium.    (See  page  338.) 

Calcium  salts  have  also  been  used  in  the  treatment  of  this  con- 
dition on  the  ground  that  it  is  due  to  a  lack  of  calcium  in  the  tissues. 
Netter,  Meyer,  Zybell  ^  and  Sedgwick  have  obtained  favorable 
results  with  'them.  Rosenstern  ^  was  able  to  reduce  the  electrical 
excitabihty  temporarily  by  giving  large  amounts  of  calcium  by 
mouth.  Other  observers  have  not  been  able  to  obtain  such  favor- 
able results.  When  it  is  impossible  to  get  human  milk,  it  is  worth 
while,  however,  to  try  the  calcium  salts.  The  best  form  to  use  is 
dessicated  calcium  chloride.  It  should  be  given  in  doses  of  ten 
grains,  six  or  seven  times  daily. 

Berend  '  has  obtained  favorable  results  by  the  use  of  subcutane- 
ous injections  of  anhydrous  magnesium  sulphate,  which  seems 
indicated  an  account  of  the  probable  disturbance  of  the  calcium 
balance  and  because  of  its  depressing  effect  on  the  nervous  system. 
He  used  from  20  eg.  to  40  eg.  of  an  8%  solution  per  kilogram  of 
body  weight. 

Because  of  the  diminution  in  the  amount  of  the  calcium  salts  in 
the  tissues  after  parathyroidectomy  and  the  probability  that 
spasmophilia  is  due  to  a  lack  of  calcium,  it  was  suggested  that  the 
administration  of  parathyroids  or  of  parathyroid  extract  by  mouth 

» Netter:  Archiv.  f.  Kinderh.,  1903,  xxxv,  473;  Meyer:  Jahrb.  f.  Kinderh., 
1911,  Ixxiv,  560;  Zybell:  Muench.  Med.  Woch.,  1911,  Iviii,  2357  and  Jahrb.  f. 
Kinderh.,  1913,  Ixxviii,  Supp.  29). 

'  Rosenstern:  Jahrb.  f.  Kinderh.,  1910,  Ixxii,  154. 

'  Berend:  Monatschr.  f.  Kinderh.,  1913-14,  xii,  260. 


360  TREATMENT 

might  be  of  service.  Thus  far  no  favorable  results  have  been 
obtained  in  this  way.  Moreover,  MacCallum  and  Vogel  *  found 
that  the  administration  of  parathyroids  did  not  increase  the  cal- 
cium content  of  the  blood. 

^  MacCallum  and  Vogel:  Joum.  Exp.  Med.  1913,  xviii,  618. 


CHAPTER  XXX 
ACIDOSIS 

Acidosis  is  a  symptom  and  not  a  disease.  It  is  characterized 
by  air  hunger  in  which  the  normal  abdominal  type  of  respiration 
is  replaced  by  one  which  is  both  costal  and  abdominal.  There  is 
a  greater  ampUtude  in  the  respirations  which  are  made  with  a 
distinct  effort.  There  is  a  diminished  amomit  of  alkaU  in  the 
blood  and  a  low  carbon  dioxide  content  in  the  alveolar  air.  There 
may  or  may  not  be  acetonuria.  Acidosis  is  one  of  the  sjrmptoms 
of  "intestinal  intoxication." 

Reaction  of  the  Blood. — The  reaction  of  the  blood  is  normally 
alkaline  and  is  maintained  at  a  remarkably  constant  level  by  a  very 
deUcate  and  complicated  mechanism.  The  products  of  metabolism 
are  acid  and  there  is,  therefore,  a  constant  stream  of  acid  poured 
into  the  blood,  which  must  be  carried  to  the  organs  of  excretion  to 
prevent  its  accumulation  in  the  body.  If  these  acids  should  ac- 
cumulate in  sufficient  quantity  to  change  the  reaction  of  the 
blood  toward  acidity,  acidosis  would  result  and  if  the  accumulation 
of  acid  should  become  sufficiently  concentrated,  death  would  en- 
sue. The  delicate  mechanism  regulating  and  maintaining  the 
normal  reaction  of  the  blood  is,  therefore,  one  of  the  conspicuous 
factors  of  safety.  The  far  reaching  investigations  of  Henderson  ^ 
and  his  co-workers  on  problems  relating  to  the  reaction  of  the 
body  fluids  have  laid  the  foundation  for  our  knowledge  of  acidosis. 

One  of  the  end  products  of  metaboHsm  which  is  constantly  flow- 
ing into  the  blood  is  carbonic  acid.  It  is  carried  away  from  the 
cells  by  the  tissue  juices  and  blood  in  solution  as  sodium  bicarbon- 
ate. In  order  that  this  may  be  accomplished,  there  must  be  20 
parts  of  sodium  bicarbonate  in  the  blood  for  each  part  of  carbonic 
acid  which  is  being  carried  to  the  lungs.  When  it  reaches  the  finer 
capillaries  of  the  lungs,  it  is  exposed  to  air,  which  has  a  lower  carbon 
dioxide  tension  than  that  of  the  blood,  and  it  diffuses  from  the  blood 
into  the  air  until  the  carbon  dioxide  tension  of  the  blood  is  lowered 

^  Henderson:  Am.  Jour.  Physiol.,  1908,  xxi,  427;  Join-.  Biol.  Chem.,  1911,  ix, 
403;  Henderson  &  Palmer;  Jour.  Biol.  Chem.,  1912-13,  xiii,  393;  1913,  xlv, 
81;  1914,  xvii,  306;  Yandell,  Henderson  &  Haggard:  Jour.  Biol.  Chem.,  1918, 
xxxiii,  333. 

361 


362  ACIDOSIS 

to  that  of  the  air.  It  is  excreted  as  carbon  dioxide  and  water.  The 
blood,  then  being  reUeved  of  its  load  of  carbonic  acid,  passes  again 
through  the  body  picking  up  a  new  load  to  carry  to  the  lungs. 
When  an  excess  of  carbonic  acid  is  formed  as  a  result  of  muscular 
exercise,  the  respiratory  center  is  stimulated,  the  heart  beats 
faster,  and  the  acid  is  promptly  carried  to  the  lungs  and  eliminated. 
It  is  practically  impossible  to  detect  any  accumulation  of  acid  in 
the  blood,  owing  to  the  nicety  in  which  the  delicate  mechanism 
reacts  to  the  slightest  stimulus.  The  balance  of  acids  and  bases  is 
kept  practically  unaltered  except  in  extreme  acidosis  immediately 
preceding  death. 

There  are  other  acids  resulting  from  the  metabolism  which 
must  be  excreted  from  the  body,  the  most  important  of  which 
are  phosphoric  acid  and  sulphuric  acid.  Phosphoric  acid  ordi- 
narily is  carried  in  the  blood  by  the  dibasic  phosphates.  There 
must  be  12.5  parts  of  dibasic  phosphate  for  every  part  of  phos- 
phoric acid  carried.  The  combined  acid  and  base  are  eliminated 
in  the  urine  and  during  the  process  some  base  is  lost  from  the  body. 
This  is  quite  different  from  the  elimination  of  carbonic  acid  which 
is  eliminated  through  the  lungs  without  removing  any  base  from 
the  body.  Since  the  bases  are  necessary  for  the  maintenance  of  the 
acid-base  equilibrium  of  the  body,  the  bases  which  are  excreted  in 
the  urine  must  be  replaced,  otherwise  a  diminished  "alkali  re- 
serve" would  result  with  acidosis.  A  new  supply  of  bases  is  ob- 
tained from  the  food,  which  supplies  enough  to  replace  those  which 
are  excreted  in  the  urine. 

The  bases  are  an  essential  part  in  the  mechanism  of  carrying 
the  acid  end  products  of  metabolism  to  the  organs  of  secretion. 
The  body  can  adapt  itself  to  abnormal  accumulations  of  acids 
either  by  increasing  the  ventilation  of  the  lungs  or  by  increasing  the 
carbon  dioxide  capacity  of  the  blood.  The  latter  is  apparently 
accomplished  by  drawing  upon  the  "alkaU  reserve"  and  drawing 
alkali  from  the  tissues  into  the  blood.  Acids  may  also  combine 
with  ammonia  which  can  be  derived  from  urea,  a  neutral  substance. 
The  ammonia  in  this  case  replaces  some  of  the  alkaline  salts  and 
allows  the  salts  to  combine  with  other  acids.  The  presence  of  an  in- 
creased amount  of  anunonia  in  the  urine  does  not,  in  itself,  indi- 
cate an  acidosis  but  rather  that  the  body  is  reacting  to  prevent 
acidosis. 

"So  long  as  the  eUminating  mechanism  for  the  excretion  of 
acids  is  preserved,  the  "alkali  reserve"  is  not  affected,  even 
though  the  production  of  acids  may  be  greatly  increased.  When 
acids  are  produced  in  excess  or  their  elimination  is  interfered  with, 


ACIDOSIS  363 

the  normal  preponderance  of  bases  over  acids  is  disturbed  and 
acidosis  results."  ^ 

Causes  of  Acidosis. — The  far  reaching  investigations  of  How- 
land  and  Marriott,  supplemented  recently  by  those  of  Schloss  have 
opened  the  field  for  the  study  of  acidosis  in  infancy.  Although 
much  fight  has  been  thrown  on  the  subject  there  yet  remains  much 
to  be  learned.    The  causes  may  be  roughly  grouped  as  follows: 

(1)  Diarrhea  in  which  there  is  an  abnormal  loss  of  alkafi  from 
the  bowels  and  an  insufficient  intake  in  the  food  to  make  up  for 
the  loss. 

(2)  Nephritis  in  which  the  kidney  is  incapable  of  excreting  the 
acids  normally  found  in  the  metabolism.  There  is  not  necessarily 
an  excessive  formation  of  acids  but  there  always  is  a  diminished 
power  of  elimination. 

(3)  Perverted  metabolism  with  excessive  formation  of  normal 
or  abnormal  acids.  This  occurs  especially  in  cases  in  which  the 
metabolism  of  fat  is  abnormal,  and  results  in  the  excretion  of 
aceto-acetic  acid  and  hydroxy,  butyric  acid.  These  aeids  may  be 
formed  in  large  enough  quantities  to  neutralize  the  blood  alkali. 
There  will  then  be  too  little  base  in  the  body  to  carry  the  other 
acids  to  the  organs  of  excretion. 

Acetonuria. — The  simplicity  of  the  clinical  tests  for  the  acetone 
bodies  in  the  urine,  has  led  to  their  more  general  use  in  practice. 
Since  the  tests  are  often  positive  in  many  conditions  which  have  no 
connection  whatsoever  with  acidosis,  there  has  been  much  confu- 
sion and  loose  use  of  the  term  acidosis.  The  sodium  nitro-prusside 
test,^  will  detect  minute  quantities  of  acetone  bodies  in  the  urine, 
while  the  ferric  chloride  test  ^  is  less  delicate  and  does  not  show  the 
presence  of  acetone  bodies  in  the  urine  unless  they  are  present  in 
considerable  quantities. 

Acetone  bodies  may  appear  in  the  urine  during  starvation,  with- 
out acidosis  (see  page  67),  under  normal  conditions.  They  may 
also  be  present  in  the  urine  in  many  infections,  without  acidosis. 
Acetone  bodies  are  found  oftener  in  the  urine  of  older  children  than 

*  Holt  and  Howland:  Dis.  of  Infancy  and  Childhood,  N.  Y.  &  London,  1916, 
217. 

« To  one-sixth  of  a  test  tube  of  urine,  add  a  crystal  of  sodium  nitro-prusside 
and  a  few  drops  of  glacial  acetic  acid.  Shake,  overlay  with  ammonium  hy- 
drate. A  purple  color  appears  in  the  foam  and  at  the  line  of  juncture  of  the 
ammonia  and  urine,  if  acetone  is  present. 

'  A  strong  aqueous  solution  of  ferric  chloride  is  added  to  one-third  of  a  test 
tube  of  urine.  A  Burgundy  red  color  shows  the  presence  of  diacetic  acid.  If 
the  reaction  takes  pkwe  after  the  urine  has  been  previously  boiled,  it  is  not 
due  to  diacetic  acid. 


364  ACIDOSIS 

infants.  They  are  usually  but  not  always  present  in  acidosis. 
Acetonuria  is  frequently  the  precursor  of  acidosis,  and  is  often  con- 
fused with  the  symptom  complex  in  which  there  is  a  diminished 
alkali  reserve  in  the  blood  and  a  diminshed  carbon  dioxide  ten- 
sion of  the  alveolar  air.  It  is  sometimes  difficult  to  determine 
clinically  when  a  case  changes  from  a  simple  acetonuria  to  true 
acidosis. 

The  carbon  dioxide  tension  of  the  alveolar  air,  may  be  de- 
termined by  the  method  described  by  Rowland  and  Marriott.^ 
This  method  gives  more  evidence  of  value  than  does  either  of  the 
tests  for  acetone  bodies.  It  is  simple  and  sufficiently  accurate  for 
all  clinical  purposes.  Like  all  chemical  methods,  it  requires  prac- 
tice to  obtain  an  efficient  technique,  the  greatest  care  being  taken 
to  obtain  a  true  sample  of  the  alveolar  air.  The  mistake  of  making 
too  low  readings  is  commoner  than  too  high  readings.  If  the  di- 
rections given  by  Rowland  and  Marriott  are  carried  out  exactly, 
duplicate  readings  should  be  obtained  which  will  give  an  accurate 
estimate  of  the  carbon  dioxide  elimination  from  the  body.  The 
normal  carbon  dioxide  tension  of  the  alveolar  air  in  infancy  is  be- 
tween 37  and  45  mm.  A  lowered  tension  indicates  acidosis.^  A 
tension  below  30  indicates  a  severe  acidosis,  and  below  20  extreme 
acidosis. 

Van  Slyke  has  especially  emphasized  the  importance  of  measuring 
the  carbon  dioxide  capacity  or  "alkali  reserve"  of  the  blood  as  an 
even  more  reliable  index  of  acidosis  than  the  carbon  dioxide  ten- 
sion of  the  alveolar  air.  Since  it  is  difficult  to  obtain  the  necessary 
amounts  of  blood  from  sick  infants,  this  test  has  not  become  a  com- 
mon clinical  procedure  but  has  been  used  for  scientific  investi- 
gation. The  Sellards  test,  the  capacity  of  the  body  to  absorb  bi- 
carbonate of  soda  without  turning  the  urine  alkaline  is  also  of 
value  in  estimating  the  "  alkali  reserve."  The  most  important  test 
in  cUnical  practice,  up  to  date,  is  the  determination  of  the  carbon 
dioxide  tension  of  the  alveolar  air. 

Clinical  Symptoms. — Acidosis  in  infancy  is  usually  associated 
with  vomiting  and  diarrhea,  but  it  may  be  present  without  either  of 
these  symptoms.  Drowsiness,  when  it  occurs,  is  a  later  symptom. 
There  is  usually  an  odor  of  acetone  on  the  breath,  and  chemical 
tests  show  the  presence  of  acetone  bodies  in  the  urine.  The  first 
symptom  of  importance  is  an  increase  in  the  depth  of  respiration 
which  soon  becomes  air  hunger.  This  is  due  to  the  increased  car- 
bon dioxide  in  the  blood  which  stimulates  the  respiratory  center 

*  Howland  and  Marriott:  Am.  Jour.  Dis.  Children,  1916,  xi,  309. 
^Howland  and  Marriott:  Bull.  Johns  Hopkins  Hosp.,  1916,  xxvii,  63. 


ACIDOSIS  365 

with  the  purpose  of  increasing  the  puhnonary  ventilation.  "The 
increased  puhnonary  ventilation  may  go  on  uninterrupted  for 
hours.  Eventually,  in  fatal  cases,  the  respirations  become  fee- 
bler and  feebler  with  only  occasional  deep  gasps,  and  finally  they 
cease  altogether."^  Instead  of  being  cyanotic,  the  color  of  the  lips 
is  often  bright  red.  There  is  frequently  evidence  of  great  loss  of 
fluid  from  the  body,  depending  on  the  severity  of  the  vomiting  and 
the  diarrhea.  The  temperature  may  be  shghtly  elevated  or  high 
according  to  the  underlying  disease. 

Schloss  ^  showed  that  the  phenolsulphonephthalein  elimination 
of  the  kidneys  and  the  water  elimination  are  greatly  diminished. 
It  has  long  been  known  that  albumen  and  casts  are  present  in  the 
urine  of  infants  affected  with  severe  diarrhea;  the  degree  of  albu- 
minuria, however,  is  rarely  great.  Both  of  these  facts  indicate 
that  the  kidney  is  not  functioning  normally. 

Acidosis  may  compUcate  infectious  diarrhea,  "intestinal  intox- 
ication," pneumonia,  nephritis,  cychc  vomiting,  and  severe  res- 
piratory infections.  It  may  be  mistaken  for  the  onset  of  menin- 
gitis acute  surgical  conditions  in  the  abdomen,  general  septicaemia, 
and  pneimionia. 

Pathology. — ^There  are  no  outstanding  features  in  the  pathology 
of  acidosis.  According  to  Lacker  and  Gauss  '  there  is  Upemia  from 
failure  of  the  body  tissues  to  utilize  the  fat  in  the  blood  and,  as  a 
result,  lipuria.  They  also  find  fatty  infiltration  of  the  fiver  and 
fatty  degeneration  of  the  kidneys.  Lesions  in  the  kidneys  are  by 
no  means  the  rule,  as  they  were  absent  in  five  of  the  eight  cases 
reported  by  Schloss.  The  intestinal  mucosa  is  sometimes  con- 
gested, but  as  a  rule  is  pale  and  somewhat  atrophic.  Small  ero- 
sions of  the  duodenal  mucosa  occur  in  some  cases. 

Prognosis. — ^The  prognosis  depends  both  on  the  imderlying 
disease  and  the  treatment.  Cases  with  acetonuria  only,  practi- 
cally always  recover.  When  the  stage  of  air  hunger  is  reached  with 
a  diminished  carbon  dioxide  tension  of  the  alveolar  air,  the  prog- 
nosis is  influenced  a  great  deal  by  the  treatment.  The  lower  the 
carbon  dioxide  tension  of  the  alveolar  air,  the  graver  the  prog- 
nosis. When  the  tension  is  below  20  the  prognosis  is  grave  even 
with  energetic  and  appropriate  treatment. 

Treatment. — The  treatment  depends  upon  the  clinical  appear- 
ance of  the  patient  and  upon  the  chemical  findings.  If  the  disease 
commences  with  digestive  symptoms  and  there  is  evidence  of  fer- 

*  Howland  and  Marriott:  loc.  cU. 

»  Schloss:  Am.  Jour.  Dis.  ChUdren,  1918,  xv,  165. 

>  Lacker  and  Gauss:  Am.  Jour.  Dis.  Children,  1917,  xiii,  209. 


366  ACIDOSIS 

mentation  or  putrifaction  in  the  lower  bowel,  a  cathartic  should  be 
given  to  remove  the  accumulation  of  fecal  material  and  gas.  Cas- 
tor oil,  which  works  more  rapidly  than  the  other  cathartics  com- 
monly used,  should  be  given  in  doses  varying  from  two  teaspoons 
to  one  tablespoon  according  to  the  age  of  the  infant.  Since  castor 
oil  is  often  vomited,  calomel  1/10  grain  every  one  half  hour  for  ten 
doses,  followed  by  a  teaspoon  of  milk  of  magnesia,  may  be  given 
to  those  infants  in  which  vomiting  is  a  prominent  symptom. 
Calomel  should  not  be  repeated  in  less  than  three  days  because  it 
is  in  itself  an  irritant.  After  the  retained  fecal  material  and  gas 
has  been  cleared  out  of  the  bowels,  a  severe  watery  diarrhoea  with- 
out gas  may  commence.  Physical  examination  shows  a  scaphoid 
abdomen.  At  this  stage  cathartics  are  contra-indicated  because 
the  bowels  are  emptying  themselves  very  rapidly,  and  because 
much  fluid  and  salts  are  being  drawn  from  the  body  in  the  liquid 
stools.  This,  if  long  continued,  will  result  in  lowering  the  "alkali 
reserve"  in  the  blood,  and  cause  true  acidosis.  The  loss  of  liquid 
and  alkali  from  the  body  should,  therefore,  be  stopped  as  recom- 
mended by  Rowland  and  Marriott  ^  Paregoric  should  be  given  in 
doses  of  from  two  to  four  minims  after  each  movement  of  the 
bowels,  the  dose  varying  with  the  age  of  the  infant.  Such  dosing 
regulates  itself  with  the  severity  of  the  diarrhea,  and  may  be 
omitted  when  the  number  of  stools  have  been  reduced  to  three  a 
day. 

The  most  important  single  factor  in  the  treatment  of  acidosis, 
is  to  maintain  the  body  fluid.  This  can  not  be  done  intelligently 
unless  a  written  record  is  kept  of  every  ounce  of  fluid  taken  and 
retained  by  the  patient.  It  is  also  very  helpful,  if  the  nurse  can 
measure  or  estimate  the  amount  of  fluid  lost  in  the  urine  and 
stools.  This,  however,  is  usually  impossible  in  young  infants.  On 
physical  examination  an  idea  may  be  obtained  of  the  state  of  the 
fluids  of  the  body  by  examining  the  fontanelle,  (depressed  fon- 
tanelle  means  loss  of  fluid),  the  skin  (dry  skin  means  a  dried  out 
body),  and  tongue  (a  red  glairy  dry  tongue  and  mucus  mem- 
brane means  the  same).  Treatment  should  be  instituted  to  first 
prevent  drying  out  of  the  body  and  secondly  to  replace  the  body 
fluid  that  has  already  been  lost.  The  technique  of  administering 
fluid  varies  with  the  individual  case.  When  possible  water  should 
be  given  by  mouth.  Small  amounts  of  liquid  are  usually  retained 
when  larger  amounts  are  vomited.  Liquids  should  be  first  given 
in  teaspoon  doses  every  five  minutes  throughout  the  twenty-four 
hours  while  the  infant  is  awake.  This  is  usually  easy  where  there 
*  Howland  &  Marriott:  Trans.  Am.  Ped.  Soc,  1915,  xxvii,  200. 


ACIDOSIS  367 

is  intense  thirst  and  restlessness.  The  amount  and  the  intervals 
are  increased  when  warranted  by  the  clinical  symptoms.  Usually 
the  dose  is  increased  when  the  child  goes  two  or  three  hours  with- 
out vomiting. 

If  water  is  not  retained  by  mouth,  it  should  be  introduced  by 
rectum.  Since  only  small  amounts  can  be  introduced  by  enema 
at  a  time,  it  is  best  given  by  the  Murphy  drip  method.  A  very 
good  way  is  to  allow  the  water  to  run  in  for  two  to  three  hours 
and  then  rest  the  bowel  for  an  equal  period  of  time  before  intro- 
ducing the  catheter  again.  This  often  makes  it  possible  to  con- 
tinue the  administration  of  liquids  through  the  bowels  over  a  longer 
period  of  time  than  if  the  tube  were  allowed  to  remain  in  continu- 
ously. If  diarrhea  is  present  the  tube  will  not  be  retained  except 
when  carefully  and  skillfully  handled.  Since  it  is  essential  that  liq- 
uid be  introduced  into  the  body,  in  cases  where  it  is  not  retained 
by  either  the  stomach  or  rectum  it  must  be  introduced  in  other 
ways. 

Subcutaneous  or  intravenous  infusion  of  liquid  are  the  last  re- 
sorts and  in  severe  cases  should  be  used  immediately.  Three  to  six 
ounces  of  liquid  may  be  introduced  subpectorally,  or  by  intraven- 
ous injection.  Intravenous  injections  of  liquid  are  very  difficult  in 
infancy  owing  to  the  small  size  of  the  veins.  The  best  results 
have  been  obtained  by  putting  it  directly  into  the  lateral  sinus. 

T3rpe  of  Liquids  to  be  Used. — Very  often  the  stomach  can  retain 
water  only.  If  there  is  air  hunger  or  a  lowered  carbon  dioxide 
tension  of  the  alveolar  air  75  to  150  c.  c.  of  4%  bicarbonate  of 
soda  solution  must  be  introduced  into  the  body  subcutaneously  or 
intravenously.  If  it  is  used  subcutaneously  or  intravenously,  it 
should  be  sterile.  Care  should  be  taken  that  none  of  the  bicar- 
bonate of  soda  has  changed  into  sodium  carbonate  which  is  irri- 
tating and  may  cause  a  slough.  (Directions  for  the  preparation  of 
the  sterile  bicarbonate  solutions  are  given  in  the  paper  by  How- 
land.)  The  intravenous  treatment  should  not  be  persisted  in  after 
the  urine  becomes  alkaline. 

Sugars  may  also  be  introduced  into  the  body.  There  are  two 
reasons  why  this  should  be  done.  First:  during  starvation  (per- 
sistent vomiting  is  starvation)  sugar  is  quickly  used  up  in  supply- 
ing the  body  with  fuel  to  make  the  energy  necessary  for  life. 
Secondly  it  prevents  the  formation  of  the  acetone  bodies  and  thus 
tends  to  prevent  acidosis.  Orange  juice  may  be  given  in  small 
amounts  by  mouth.  The  young  infants  may  be  given  5%  solution 
of  milk  sugar,  or  cane  sugar.  Sugar  solutions  may  be  given  by 
rectum,  subcutaneously  or  intravenously  according  to  the  ex- 


368  ACIDOSIS 

igencies  of  the  case.  When  given  by  rectum  it  may  be  given  in  a 
5  to  10%  solution:  when  given  under  the  skin  or  into  a  vein,  it 
should  contain  5%  or  less.  The  best  sugar  to  employ  under  these 
circumstances  is  chemically  pure  glucose  (dextrose)  which  is  the 
same  sugar  normally  present  in  the  blood  and  requires  no  diges- 
tion before  it  can  be  used.  Corn  syrup  (Karo),  is  a  cheap  and 
satisfactory  form  of  glucose  to  use  in  rectal  enemata.  It  is  not 
pure  enough  to  inject  directly  into  the  blood. 

Food. — As  has  been  stated  above,  a  sufficient  amount  of  hquid 
to  carry  the  waste  products  of  the  body  through  the  kidneys  in  a 
sufficiently  diluted  form  as  not  to  damage  the  kidneys  is  one  of  the 
essentials  of  the  successful  treatment  of  acidosis.  The  food,  how- 
ever, may  be  regulated  in  such  a  manner  as  to  lessen  the  burden 
of  the  body.  Since  acetone  bodies  are  formed  primarily  from  fat, 
fat  should  be  excluded  from  the  food  when  given.  Sugars  should 
be  given  when  possible  to  prevent  the  formation  of  acetone  bodies. 
Since  the  starches  are  converted  by  the  digestion  into  sugar  they 
may  be  given  in  the  form  of  barley  water  or  some  cereal  concoction 
and  in  older  infants  in  the  form  of  barley  jelly.  Although  pro- 
teins may  take  part  in  the  formation  of  acetone  bodies,  they  do  not 
seem  to  do  so  in  sufficient  amounts  to  be  of  any  clinical  importance. 


INDEX  OF  NAMES 


Adriance,  on  chemistry  of  colostrum, 

104 
Albertoni,    on   purgative   action    of 

sugars,  38 
Albu-Neuberg,    on    mineral    metab- 
olism, 58 
Alwens    and    Husler,    on    shape    of 

stomach,  4 
Allaria,  on  reaction  of  mouth,  3 
Allen,     on    intoxicating    action    of 

sugars,  41 
Arndt,  on  calcium  retention,  336 
Aron  and  Sebauer,  on  experimental 

rickets,  332 
Aschenheim,    on    mineral    salts    in 

spasmophiha,  356 
Aschner    and    Grigori,    on    galacta- 

gogues,  125 
Ayers  and  Johnson,  on  pasteurized 

milk,  182 

Babcock,  on  nitrogenous  compounds 

of  milk,  166 
Bahrdt,  on  absorption  of  fat,  25,  26; 

on  infantile  atrophy,  29 
Bahrdt  and  Bamberg,  on  acidity  of 

stools,  37 
Bahrdt  and  Beifeld,  on  bacteriology 

of  intestines,  83 
Bahrdt  and  Edelstein,  on  chemistry 

of  scurvy,  348;  on  fatty  acids  in 

milk,  159;  on  iron  in  human  milk, 

121 
Bahrdt  and  McLean,  on  acidity  of 

stools,  37 
Baker,    on   intracutaneous   test   for 

dysentery  bacillus,  306 
Bartenstein,  on  experimental  scurvy, 

345 
Basch,    on    influence    of    ovary    on 

breast,  126;  on  placental  extract, 

125 
Bauer,  on  differentiation  of  human 

milk,  129;  on  protein  of  colostnun, 

106 


Baumann  and  Howard,  on  me- 
tabolism in  scurvy,  348 

Bayliss  and  Starling,  on  secretion, 
15,44 

Beck,  on  caloric  requirements,  73 

Behring,  on  alexins,  181 

Bendix,  on  menstruation  and  lacta- 
tion, 128 

Benedict  and  Talbot,  on  body  surface 
and  metabolism,  67;  on  body 
weight  and  metabohsm,  68;  on 
effect  of  exercise  on  metabolism, 
66;  on  fasting  metabolism,  67;  on 
gaseous  metabohsm,  64 

Benjamin,  on  casein  curds,  49 

Berend,  on  treatment  of  hemophilia, 
359 

Bergell  and  Langstein,  on  analysis  of 
casein,  114 

Berger,  on  alimentary  anaphylaxis, 
51;  on  salivary  glands,  1 

Bergmann,  on  body  surface  and 
metabolism,  67 

Bergmark,  on  alimentary  glycemia,  36 

Bessau,  on  bacteriology  of  gastro- 
intestinal canal,  77 

Biedert,  on  casein  curds,  46;  on  fat 
diarrhea,  27 

Bienenfeld,  on  coagulation  of  human 
milk,  110 

Birk,  on  mineral  metabohsm,  61; 
on  phosphorus  in  rickets,  339 

Blauberg,  on  phosphorus  metabolism, 
60 

Block,  on  exclusive  carbohydrate 
diet,  38 

Bloor,  on  absorption  of  fat,  21,  22 

Bolle,  on  experimental  scurvy,  345 

Bonnoit,  on  gaseous  metabolism,  64 

Bordet,  on  specificity  of  proteins  of 
milk,  115 

Bosworth,  on  action  of  sodium  cit- 
rate, 12 

Bosworth  and  Van  Slyke,  on  casein, 
163 


369 


370 


INDEX  OF  NAMES 


Bowditch,     on     calculating     caloric 

values,  240 
Bowditch  and  Bosworth,   on   dried 

casein,  224 
Brennemann,   on   casein   curds,   49; 

on    rennin    coagulation    of   boiled 

milk,  216 
Brown  and  Fletcher,  on  spasmophilia, 

354,  356 
von    Brunning,    on    digestibiUty    of 

heated  milk,  183 
Buchholz,   on  colostrum  corpuscles, 

105 
Bundin,  on  caloric  requirements,  73 

Caldwell,  on  breast  pumps,  141 

Camerer  and  Soldner,  on  calcium 
metabolism,  332;  on  chemistry  of 
colostrum,  104;  on  protein  of  hu- 
man milk,  111 

Cannon,  on  absorption  in  stomach, 
14;  on  duration  of  gastric  digestion, 
6;  on  function  of  stomach,  8 

Carel,  on  scurvy  and  heated  mUk, 
184,  344 

Carlson  and  Ginsberg,  on  gastric 
hunger,  7 

Carpenter  and  Murlin,  on  energy 
metabohsm  in  pregnancy,  65 

Cathcart,  on  protein  synthesis,  38 

Chapin,  on  caloric  value  of  food,  199 

Chapin  and  Pisek,  on  fat  percentage 
in  bottled  milk,  230 

Chatin  and  Rendu,  on  milk  as  galac- 
tagogue,  126 

Ciccarelli,  on  proteins  of  human 
milk,  114 

Clark,  on  action  of  hme  water,  12; 
on  reaction  of  human  milk,  108 

Cobliner,  on  pyrogenic  effect  of 
sodium  halogens,  40 

Cohnheim,  on  antitrypsin,  44;  on 
erepsin,  45 

Courant,  on  coagulation  of  mUk  by 
rennin,  163 

Courtney,  on  absorption  of  fat,  26; 
on  casein  curds,  48;  on  mineral 
metabolism,  62;  on  nitrogen  re- 
tention, 54 

Cowie,  on  alkaUes  in  pyloric  spasm, 
257 

Cowie  and  Lyon,  on  pyloric  reflex,  8 

Cramer,  on  caloric  requirements,  72; 


on  influence  of  ovary  on  breast,. 
126;  on  quantity  of  milk  secretion, 
108 

Cronheim  and  Miiller,  on  calcium  re- 
tention, 336;  on  nitrogen  excretion, 
52 

Czerny,  on  colostnun,  103;  on  colos- 
trmn  corpuscles,  105;  on  exudative 
diathesis,  31 

Czerny  and  Keller,  on  absorption  of 
fat,  25;  on  caloric  requirements,  73 
on  chemistry  of  human  milk,   103 
on  feeding  of  premature  infant,  251 
on   influence   of  food   on   human 
milk,  124 

Czerny  and  Steinitz,  on  metabohsm 
in  digestive  disturbances,  55 

Davis,  on  mortahtv  of  artificially- 
fed,  99 

Debele,  on  length  of  intestines,  18 

De  Jager,  on  digestibihty  of  heated 
milk,  183- 

De  Just  and  Constant,  on  starch  in 
stools,  95 

Demrae,  on  fat  diarrhea,  27 

Dennett,  on  caloric  requirements,  73 

Deville,  on  colostrum  corpuscles,  106 

Dibbelt,  on  calcium  in  hmnan  milk, 
333 

Dluski,  on  "running  in"  of  human 
milk,  134;  on  statistics  of  breast 
feeding,  100 

Dodd,  on  exp)erimental  scurvy,  347 

Dimdin,  on  reaction  of  stomach,  11 

Ehrhch,  on  transmission  of  immunity 
through  milk,  132 

Engel,  on  coagulation  of  human 
milk,  110;  on  fat  in  human  milk, 
116;  on  gastric  secretions,  10;  on 
protein  in  human  milk,  113 

Engling,  on  composition  of  cow's 
milk,  157 

Erdheim,  on  parathyroids  in  spas- 
mophilia, 357 

Escherich,  on  bacteriology  of  stom- 
ach, 78;  on  bacteriology  of  stools, 
85;  on  casein  curds,  46;  on  en- 
dogenous intestinal  infection,  80; 
on  intoxicating  effect  of  sugars,  41 

Feer,  on  amount  of  milk  at  nursing, 
lOiS;  CHI  caloric  requirements,  72 


INDEX  OF  NAIVIES 


371 


Ficker,  on  bacteriology  of  intestine, 

80 
Fife  and  Veeder,  on  infantile  atrophy, 

29,  55 
Finizio,  on  fat  in  stools,  31;  on  pro- 
tein   of    human    milk,     128;    on 

salivary  amylolysis,  3 
Finkelstein,  on  caloric  requirements, 

73;  on  effects  of  heated  milk,  184; 

on  etiology  of  digestive  disturb- 
ances, 39,  40 
Finkelstein  and  Meyer,  on  intestinal 

fermentation,  40,  222 
Fisher  and  Moore,  on  absorption  of 

sugars,  39 
Fleiscbmann,     on     digestibility     of 

heated  milk,  183 
Fliigge,  on  bacteria  of  milk,  181 
Folin  and  Denis,  on  absorption  of 

amino  acids,  46 
Folin  and   Wentworth,    on   fat  me- 
tabolism, 24 
Ford  and  Blackfan,  on  bacteriology 

of  intestines,  83 
Forster,  on  gaseous  metabolism,  64 
Fraley,  on  calculating  caloric  values, 

240 
Freeman,  on  ferments  in  milk,  130 
FriMse,  on  antiscorbutics,  353 
Freund,   on  absorption  of  fat,   25; 

on  chlorides  of  human  milk,  121; 

on  fat  in  calcium  metabolism,  335; 

on  infantile  atrophy,  29 
Friberger,    on    pyrogenic    effect    of 

sodium  halogens,  40 
Frolich,  on  experimental  scurvy,  345 
Funk,  on  vitamins,  349 
Ftirst,  on  experimental  scurvy,  345, 

347 

Gamble,  on  nitrogen  excretion,  56; 

on  spasmophilia,  354 
Gaus,  on  caloric  requirements,  72 
Gavin,  on  pituitary  extract,  125 
Gephart  and  Czonka,  on  fat  metab- 
olism, 24 
Geptner,  on  composition  of  bile,  17 
Gittings,    on    caloric    requirements, 

73 
Grosz,  on  excretion  of  sugars,  38 
Grulee,  on  spasmophiha,  354,  357 
Grulee  and  Caldwell,  on  menstrua- 
tion and  lactation,  128 


Gundobin,  on  absorption  in  stomach, 
14;  on  pancreatic  ferments,  15 

Haberfeld,  on  parathyroids  in  spas* 
mophiha,  357 

Hahn,  on  alimentary  anaphylaxis,  51; 
on  gastric  acidity,  12;  on  rennin,  13 

Hallion  and  Lequeux,  on  secretion, 
45 

Hamburger,  on  alimentary  anaphy- 
laxis, 50 

Hamburger  and  Sperk,  on  hydro- 
chloric acid,  11 

Ebimmarsten,  on  coagulation  of  milk 
by  rennin,  162 

Hammett  and  McNeille,  on  placental 
extract,  125 

Hammond,  on  galactagogues,  125 

Hart,  on  experimental  scurvy,  347 

Hartge,  on  size  of  pancreas,  14,  15 

Hayaslei,  on  infantile  atrophy,  29 

Hecht,  on  digestion  of  fat,  30;  on 
infantile  atrophy,  29,  30;  on 
trypsin  in  stools,  44 

Hedenius,  on  carbohydrates  in  stools, 
36 

H^don,  on  purgative  action  of  sugars, 
38 

Helmholtz,  on  pyrogenic  effect  of 
sodium  halogens,  40 

Henderson,  on  acidosis,  361 

Herter  and  Kendall,  on  bacteriology 
of  intestines,  84 

Hess,  on  amylolytic  ferments,  34; 
on  antiscorbutics,  352;  on  bac- 
teriology of  duodenum,  79,  80; 
on  gastric  lipase,  10;  on  hydro- 
chloric acid,  11;  on  hpase,  15;  on 
scurvy  as  deficiency  disease,  350 

Hess  and  Fish,  on  blood  in  scurvy,  342 

Heubner,  on  caloric  requirements,  72; 
on  caloric  value  of  milk,  177;  on 
energy  quotient,  71;  on  lactic  acid 
in  stomach,  10 

Heubner  and  Lippschultz,  on  ex- 
perimental scurvy,  347 

Hippius,  on  composition  of  boiled 
milk,  181 

Hoist  and  Frolich,  on  experimental 
scurvy,  345 

Holt,  on  excretion  of  salts  in  diarrhea, 
62;  on  gastric  capacity,  5;  on  in- 
fantile atrophy,  28;  on  statistics 


372 


INDEX  OF  NAMES 


of  breast  feeding,  100;  on  utiliza- 
tion of  salts,  59 

Holt,  Courtney  and  Fales,  on  ash  of 
human  milk,  120 

Holt  and  Levene,  on  casein,  50 

Hoobler,  on  effect  of  diet  on  human 
milk,  124;  on  effect  of  diet  on  pro- 
teins of  milk,  148;  on  magnesium 
metabolism,  60;  on  mineral  me- 
tabolism, 58;  on  protein  need,  56 
on  utilization  of  salts,  59 

Howland,  on  alimentary  anaphylaxis, 
50;  on  carbohydrates  in  calcium 
metaboUsm,  335;  on  casein  curds, 
48;  on  exercise  and  metabolism,  66; 
on  fasting  metabohsm,  66;  on 
gaseous  metaboUsm,  65;  on  min- 
eral metabolism,  61;  on  output  of 
heat,  66;  on  thymus  and  rickets, 
331;  on  tolerance  of  fat,  31 

Howland  and  Marriott,  on  acidosis 
in  diarrhea,  62;  on  calcium  me- 
tabolism in  spasmophiha,  355;  on 
carbon  dioxide  tension  of  alveolar 
air,  364 

Ibrahim,  on  amylolytic  ferments  of 
pancreas,  32;  on  amylolytic  fer- 
ments of  stomach,  32;  on  casein 
curds,  49;  on  diastase  of  saUva, 
2,  32;  on  enterokinase,  16,  44;  on 
lactase  of  intestine,  33;  on  trypsin, 
44 

Ibrahim  and  Gross,  on  secretin,  44 

Jackson  and  Moody,  on  infectious 

nature  of  scurvy,  343 
Jackson  and  Moore,  on  experimental 

scurvy,    350;    on    inanition    and 

ncurvy,  347 
Janney,  on  protein  synthesis,  38 
JappeUi,  on  absorption  of  sugars,  39 
Jeinma,   on   digestibility   of   heated 

milk,  183 
Jensen,  on  composition  of  cow's  milk, 

166 
Jordan  and  Harris,  on  bacillus  lac- 

timorbi,  177 
Judell,  on  excretion  of  salts  in  di- 
arrhea, 62 

Kassowitz,  on  pathology  of  rickets, 
331;  on  phosphorus  in  rickets,  339 


Kastle,  on  coagulation  of  milk,  159 

Kastle  and  Loevenhart,  on  lipase,  21 

Kastle  and  Porch,  on  ferments  of 
milk,  181 

Kastle  and  Roberts,  on  composition 
of  boiled  milk,  180 

Katzenellenbogen,  on  calcium  me- 
tabolism in  spasmophilia,  355 

Keefe,  on  pyloroplasty  in  pyloric 
stenosis,  266 

Keller,  on  carbohydrates  in  protein 
digestion,  37;  on  nitrogen  excretion 
in  starvation,  52;  on  phosphorus 
in  human  milk,  122 

Kendall,  on  bacteriology  of  intestine, 
82;  on  gas  bacUlus  in  infectious 
diarrhea,  303 

Kendall  and  Farmer,  on  protein- 
sparing  action  of  carbohydrates,  37 

Kissel,  on  phosphorus  in  rickets,  339 

Klose,  on  relation  of  oedema  to  salts, 
62 

Klotz,  on  bacteriology  of  stools,  85; 
on  digestion  of  starch,  212 

Knopfelmacher,  on  casein  curds,  47 

Knox  and  Ford,  on  gas  bacillus  in 
intestines,  86 

Knox  and  Tracy,  on  phosphorus 
metabolism,  61 

Kocher,  on  protein-sparing  action  of 
lactic  acid,  38 

Koeppe,  on  chemistry  of  milk,  170 

Konig,  on  chemistry  of  colostrum, 
104;  on  composition  of  goat's  milk, 
174 

Koplik,  on  statistics  of  breast  feed- 
ing, 100 

Koplik  and  Crohn,  on  infantile 
atrophy,  30 

Kowalski,  on  liver,  16 

Kramsztyk,  on  bacteriology  of  stools, 
85;  on  gastric  trypsin,  10 

Krasnagorski,  on  digestibility  of 
heated  milk,  184;  on  iron  metab- 
olism, 60 

Kumagawa  and  Suto,  on  fat  metab- 
olism, 24 

Lacker  and   Gauss,   on  lipemia  in 

acidosis,  365 
Ladd,  on  caloric  requirements,  73; 

on  duration  of  gastric  digestion,  6 
Lane-Clay pon,    on    digestibility    of 


INDEX  OF  NAMES 


373 


heated  milk,  183;  on  scurvy  and 

heated  milk,  344 
Lang   and   Fenger,    on   reaction   of 

intestines,  18 
Langendorff,  on  pepsin,  43 
Langlois,  on  gaseous  metabolism,  64 
Langstein   and   Edelstein   on   phos- 
phorus of  human  milk,  115 
Langstein  and  Steinitz,  on  excretion 

of  sugars,  39;  on  lactase  of  diseased 

intestine,  34 
Langworthy  and  Holmes,  on  digest- 

ibihty  of  fat,  21 
Lawrence,    on    typhoid    bacilli    in 

breast  milk,  107 
Laws  and  Bloor,  on  estimating  fat 

in  stools,  96 
Leach,  on  composition  of  cow's  milk, 

165 
Leopold   and   Reuss,    on   pyrogenic 

effect  of  sugars,  40 
Leschziner,  on  bacteriology  of  stools, 

85 
Liebig,  on  mineral  metabolism,  58 
Litzenberg,    on    feeding    premature 

infant,  251 
Liwschiz,  on  casein  curds,  48 
Logan,   on  bacillus  bifidus,   84;  on 

virulence  of  bacillus  coli,  80 
London,    on    absorption    of    amino 

acids,  46 
Luling,  on  infant  mortality,  99 
Lusk,  on  growth  promoting  proteins, 

57 
Lusk  and  Klocman,  on  metabolism 

in  scurvy,  348 
Lust,  on  aUmentary  anaphylaxis,  51; 

on  antiproteoly  tic  ferment  of  blood, 

45;  on  sodium  chloride  retention  in 

spasmophilia,  356 

MacCallum  and  Voegtlin,  on  cal- 
cium metabolism  in  spasmophilia, 
355 

McCoUum  and  Davis,  on  vitamins, 
56,350 

McCollum  and  Kennedy,  on  vita- 
mins, 350 

McCollum  and  Pitz,  on  experimental 
scurvy,  350;  on  infectious  nature  of 
scurvy,  343 

MacKenzie,  on  galactagogues,  125 

Mai,  on  freezing  of  milk,  171 


Major,  on  shape  of  stomach,  4 

Marfan,  on  ferments  of  milk,  186 

Marriott,  on  intoxicating  effect  of 
sugars,  42 

Martin,  on  statistics  of  breast  feeding, 
101 

Matti,  on  internal  secretions  in 
rickets,  331 

Mayerhofer  and  Roth,  on  caloric  re- 
quirements, 73 

Meigs  and  Marsh,  on  identified  sub- 
stances in  himian  milk,  122 

Mellanby,  on  etiology  of  diarrhea,  49 

Mendel  and  Keliner,  on  excretion  of 
sugars,  39 

Mettenheimer,  on  internal  secretions 
in  rickets,  331 

Meyer,  A.  H.,  on  duration  of  gastric 
digestion,  6;  on  lactic  acid  in 
stomach,  10 

Meyer,  L.  F.,  on  infantile  atrophy,  29; 
on  mineral  metabolism,  58,  61,  62; 
on  tolerance  of  fat,  31 

Mitra,  on  gastric  ferments,  45 

Michael,  on  digestibility  of  heated 
milk,  183 

Miiu-a,  on  invertin  of  intestine,  33 

Miura  and  Stoeltzner,  on  pseudo- 
rachitic  osteoporosis,  331 

Modigliani  and  Benini,  on  alimentary 
anaphylaxis,  51 

Monrad,  on  casein,  50 

Moore  and  Jackson,  on  experimental 
sciuT^,  345 

Moro,  on  amylolytic  ferments  of 
pancreas,  32;  on  bacteriology  of 
intestine,  80;  on  carbohydrate 
digestion  in  newborn,  34;  on  dif- 
ferentiation of  human  milk,  128; 
on  dyspepsia  in  breast-fed,  107; 
on  endogenous  intestinal  infection, 
80 

Moro  and  Bauer,  on  anaphylaxis  in 
marasmus,  50 

Morse,  on  casein,  50 

Mosenthal,  on  gastric  capacity,  5 

Miiller,  Ed.,  on  proteolytic  ferment 
of  saUva,  43 

Miiller,  Fr.,  on  casein  curds,  46 

Miiller  and  Cronheim,  on  digestibility 
of  heated  milk,  184 

Murlin  and  Hoobler,  on  body  sur- 
face and  metabolism,  67;  on  exer> 


374 


INDEX  OF  NAMES 


else  and  metabolism,  66;  on  gaseous 
metabolism,  65 

Nagao,  on  digestion  of  starch,  212 
Niemann,  on  alimentary  glycemia,  36 
Nob^court  and  Merklen,  on  absorp- 
tion of  fat,  25 
Noguchi,  on  mutation  of  bac.  bifidus, 

84 
Noll,  on  absorption  of  fat,  22 
Nordheim,    on    statistics   of   breast 

feeding,  100 
Nothmann,  on  lactase  of  intestine, 
34;  on  pyrogenic  effect  of  sodium 
halogens,  40 

Ohlmiiller,  on  infantile  atrophy,  28 

Oppenheimer,  on  caloric  require- 
ments, 73 

Orbdn,  on  lactase  of  diseased  in- 
testine, 34 

Orgler,  on  chemistry  of  rickets,  334; 
on  fat  in  calcium  metabolism,  335; 
on  nitrogen  metabolism,  53 

Osborne  and  Guest,  on  chemistry  of 
casein,  167 

Oshima,  on  reaction  of  mouth,  1 

Palmer  and  Eckles,  on  pigments  of 
human  milk,  117;  on  pigments  of 
milk  fat,  169 
Passini,  on  peptonizing  bacillus,  82 
Pechstein,  on  gastric  ferments,  43 
Pennington,  on  freezing  of  milk,  171 
Pfannenstill,  on  absorption  in  stom- 
ach, 14 
Pfaundler,  on  gastric  capacity,  4 
Pf  aundler  and  Schlossmann,  on  chem- 
istry of  boiled  milk,  179;  on  di- 
gestibility of  heated  milk,  183 
Pfeiffer,  on  chemistry  of  colostrum, 

104 
Pisek  and  Lewald,   on  duration  of 
gastric  digestion,  6;  on  shape  of 
stomach,  4 
Plantenza,    on    scurvy    and    heated 

milk,  185,  345 
Porter  and  Dunn,  on  tolerance  of 

lactose,  41 
Pottevin,  on  ferments  of  meconium,  33 

Quest,  on  calcium  metabolism  in 
spasmophiUa,  355 


Raczynski,  on  acidity  of  stools,  37 

Rammstedt  operation,  266 

Raudnitz,  on  chemistry  of  casein,  167; 
on  digestibility  of  heated  milk,  183 

Reiss,  on  action  of  mineral  salts,  356 

Renton  and  Robertson,  on  thymus 
and  rickets,  331 

Rettger,  on  bacteriology  of  intestines, 
84,  297 

Reuss,  on  infantile  atrophy,  30 

Reye,  on  spasmophilia,  354 

Richet,  on  gaseous  metabolism,  64 

Richmond,  on  acidity  of  milk,  160; 
on  composition  of  cow's  milk,  166 

Riesel,  on  calcimn  metabolism  in 
spasmophiha,  355 

Robertson,  on  precipitation  of  casein, 
161 

Rodella,  on  peptonizing  bacillus,  82 

Rohmann,  on  amylolysis,  35 

Rohmann  and  Nagano,  on  absorp- 
tion of  sugars,  38 

Romer,  on  transmission  of  agglutinins 
through  milk,  133 

Rosenau,  on  bacteria  of  milk,  181; 
on  composition  of  boiled  milk, 
180;  on  digestibiUty  of  heated 
mUk,  183 

Rosenfeld,  on  fat  metabolism,  24 

Rosenstern,  on  mineral  salts  in  spas- 
mophilia, 356 

Rosenthal,  on  pyrogenic  effect  of 
sugars,  40 

Rossi,  on  effect  of  saUva  on  pep- 
tolysis,  45 

Rotch,  on  menstruation  and  lacta- 
tion, 127 

Rothberg,  on  mineral  metabolism,  61 

Rubner,  on  body  surface  and  metab- 
olism, 67;  on  caloric  values,  71 

Rubner  and  Heubner,  on  gaseous 
metaboUsm,  64 

Samelson,  on  fat-spUtting  ferments, 

22 
Schabad,  on  chemistry  of  rickets,  334; 

on  skeletal  weight  of  newborn,  332; 

on  treatment  of  rickets,  339 
Schafer  and  MacKenzie,  on  galacta- 

gogues,  125 
Schaps,  on  pyrogenic  effect  of  sugars, 

40 
Schloss,  on  alimentary  anaphylaxis, 


INDEX  OF  NAMES 


375 


51;  on  cod-liver  oil  in  rickets,  338; 
on  excretion  in  acidosis,  365;  on 
intestinal  intoxication,  50;  on  pyro- 
genic  effect  of  sodium  halogens,  40 

Schlossmann,  on  caloric  requirements, 
72;  on  casein,  167;  on  casein  of 
human  milk,  114;  on  nitrogen  of 
human  milk,  112;  on  phosphorus 
of  human  milk,  122;  on  preserva- 
tion of  human  milk,  156 

Schlossmann  and  Murschhauser,  on 
fasting  metabolism,  53,  66;  on 
gaseous  metabolism,  64;  on  metab- 
oUsm  during  starvation,  75 

Schlutz,  on  pjTogenic  effect  of  so- 
dium salts,  41 

Schorer  and  Rosenau,  on  pasteuriza- 
tion of  milk,  187 

Schwarz,  on  protein  utilization,  55 

Sedgwick,  on  gastric  lipase,  10 

Seller,  on  casein  curds,  47;  on  ken- 
otoxine,  49 

Shaw,  on  salivary  diastase,  2 

Shaw  and  GUday,  an  absorption  of 
fat,  25 

Sherman,  on  casein,  167 

Siegert,  on  caloric  requirements,  72; 
on  heredity  in  rickets,  330 

Sikes,  on  phosphorus  in  human  milk, 
122 

SiU,  on  effects  of  pasteurized  milk, 
184 

Sisson,  on  bacteriology  of  intestines, 
83,  297 

Sittler,  on  bacteriology  of  intestines, 
83 

Skvortzov,  on  fat  in  hmnan  milk,  117 

Smith,  Theobald,  on  duaUty  of 
tubercle  bacillus,  176 

Soldner,  on  ash  of  human  milk,  58, 
120;  on  ash  of  newborn,  58 

Solomin,  on  composition  of  boiled 
milk,  180 

Sommerfeld,  on  boiled  milk,  179; 
on  bacteria  of  milk,  181 

Sonnenberger,  on  transmission  of 
toxins  through  milk,  132 

Southworth,  on  action  of  alkalies,  12 

Spolverini,  on  ferments  in  milk,  129 

Steinitz,  on  infantile  atrophy,  28; 
on  mineral  metabolism,  61 

Steinitz  and  Weigert,  on  fat  metab- 
olism, 31 


Stoeltzner,  on  calcium  metabolism  in 

spasmophilia,  355 
Strassburger,     on     bacteriology     of 

stools,  85 

Talbot,  on  caloric  requirements,  72; 

on  casein  curds,  46;  on  mesenteric 

tuberculosis,    30;    on   reaction    of 

fatty  stools,  27 
Talbot  and  Gamble,  on  metabolism 

during  protein  indigestion,  55 
Talbot  and  Hill,  on  absorption  of  fat, 

26;  on  acidity  of  stools,  37;  on 

utiUzation  of  salts,  59 
Talbot  and  Peterson,  on  experimental 

scurvy,  345 
Ten  Broeck,   on  dysentery  bacillus 

in  diarrhea,  86 
Thiemich,  on  uremia  and  lactation, 

128 
Thiemich  and  Mann,  on  typical  law 

of  contraction,  354. 
Tiemann,  on  colostrum,  103 
Tissier,     on     bacillus     perfringens, 

292 
Tobler,  on  butyric  acid,  79;  on  gas- 
tric digestion,  8;  on  fats  in  pyloric 

spasm,  20 
Tobler  and  Bessau,  on  mineral  metab- 

ohsm,  58 
Tobler  and  Bogen,  on  duration  of 

gastric  digestion,  7 
Tobler  and  Noll,  on  rickets,  333 
Towle  and  Talbot,  on  eczema  and 

fat,  31 
Towles,     Caroline,    on    phosphorus 

cod-liver  oil  in  rickets,  340 
Tugendreich,    on    differentiation    of 

human  milk,  129 

Uffelmann,  on  absorption  of  fat,  25; 

on  casein  curds,  46;  on  excretion  of 

fat,  26,  27 
Uffenheimer  and  Takeno,  on  casein 

curds,  48 
Usuki,  on  absorption  of  fat,  26 

Van  Slyke,  oa  alkali  reserve  of  blood, 
364;  on  nitrogenous  bodies  of  milk, 
166;  on  precipitation  of  casein, 
161 

Van  Slyke  and  Bosworth,  on  casein, 
162,  229 


376 


INDEX  OF  NAMES 


Van  Slyke  and  Meyer,  on  absorption 

of  amino  acids,  46 
Variot,  on  scurvy  and  heated  milk, 

184,  344 
Variot    and    Lavaille,    on    gaseous 

metabolism,  64 
Variot  and  Saint-Albin,  on  gaseous 

metabolism,  64 
Vaughan,  on  alimentary  anaphylaxis, 

51 

Wakabayashi  and  Wohlgemuth,  on 

intestinal  ferments,  45 
Wassermann,  on  specificity  of  pro- 
teins of  milk,  115 
Wegscheider,  on  casein  ciu-ds,  46 
Weiss,  on  gaseous  metabolism,  64 
Wentworth,  on  infantile  atrophy,  29, 

30;  on  secretin,  45 
Wernstedt,  on  casein  curds,  48 


Westcott,  on  calculation  of  formulae 

for  modified  milk,  232 
Whitehead,  on  absorption  of  fat,  22 
Wienland,  on  intestinal  antifermen- 

tos,  44 
Wilson,  on  absorption  of  fat,  22 
Wohlgemuth,    on    pancreatic    secre- 
tions, 52 
Wolf,  on  milk  as  galactagogue,  126 
Wroblewski,   on  analysis  of  casein, 
114;  on  opalisin,  114 

Yanase,  on  parathyroids  in  spasmo- 
phiUa,  357 

Zuntz,  on  calorific  value  of  oxygen,  65 
Zweifel,   on   diastase  of  saliva,   32; 

on  p>epsin,  43 
Zybell,  on  mineral  salts  in  spasmo- 
philia, 356 


INDEX  OF  SUBJECTS 


Abortion,  contagious,  177 

Acetonuria,  361,  363 

Acidosis,  50,  361;  blood  in,  361; 
etiology  of,  363;  in  fat  indigestion, 
273;  pathology  of,  363 

Actinomyces  in  cow's  milk,  177 

Adenoids,  interference  with  nursing, 
140 

Adrenalin,  316 

Agglutinins  in  human  milk,  133 

Albumin  milk  in  artificial  feeding, 
218,  222 

Alcohol,  excretion  in  human  milk,  127 

Alexins  of  cow's  milk,  181 

AUmentary  decomposition  {see  In- 
fantile atrophy) 

Alkalies,  action  of,  in  digestion,  12; 
in  artificial  feeding,  216;  efifect  on 
rennin,  163;  in  pyloric  spasm, 
257 

Amino  acids,  46,  57,  363 

Amylase  in  milk,  130 

Amylolysis,  35 

Amylopsin,  14 

Anaphylaxis,  50;  to  cow's  milk,  194; 
differentiation  of  proteins  by,  115; 
transmission  through  milk,  133 

Anemia,  constipation  in,  324 

Anthrax  bacillus  in  cow's  milk,  177 

Antibodies  in  human  milk,  132 

Antiferments  in  blood,  45;  in  intes- 
tines, 44 

Anti-rennin,  165 

Antiscorbutics,  346,  352 

Antiseptics,  intestinal,  296,  312,  313 

Antitoxin  in  human  milk,  132 

Anus,  fissure  of,  322 

Ash  (see  Mineral  salts) 

Avitaminoses,  349 

Babcock  test,  229 

Bacteria,  bacillus  acidophilus,  292, 
266;  bacillus  bulgaricus,  296;  bacil- 
lus coli,  175,  292,  302;  bacillus  per- 
fringens,   292;  bacillus  putrificus. 


292;  bacillus  pyocyaneus,  302; 
butyric  acid  baciUi,  79,  292,  297; 
in  cow's  milk,  175;  dysentery 
bacillus,  302,  306,  309;  gas  bacillus, 
86,  296,  302,  305,  310;  of  gastro- 
intestinal tract,  77;  lactic  acid 
baciUi,  79,  292,  296;  in  stools,  85, 
96;  streptococcus,  302 

Barley  water  (see  Cereal  diluents) 

Barlow's  disease  {see  Scurvy) 

Baths,  cold  pack,  315;  fan,  315; 
sponge,  315 

Bauer's  reaction,  129 

Beef  juice,  247 

Beriberi,  effect  on  human  milk,  128 

Bile,  17, 18;  in  human  milk,  128;  min- 
eral salts  in,  59 . 

Bile  ducts,  obUteration  of,  30,  92 

Bismuth,  296,  313 

Blood,  dextrose  in,  36;  lecithin  in,  22; 
in  rickets,  337;  in  stools,  94 

Bluhdorn  on  bacteriology  of  intes> 
tines,  84 

Brain,  hemorrhage,  300 

Bran,  326 

Bread  and  zweibach,  248 

Breast,  care  of,  141;  influence  of 
ovary  on,  126 

Breast-fed  infant,  abnormal,  144; 
normal,  143 

Breast  feeding  (see  Feeding,  breast) 

Breast  glands,  103 

Breast  milk  (see  MUk,  human) 

Breast  pumps,  141 

Breck  feeder,  140,  253 

Broths,  248 

Buttermilk  in  artificial  feeding,  218, 
220;  stools,  90 

But3Tic  acid,  78 

Butyric  acid  bacilli,  79,  292,  297 

Cabbage,  346 

Calcium  in  cow's  milk,  332;  in  human 
milk,  121;  metabolism  of,  59,  287, 
333;  metabolism  in  rickets,  332; 


377 


378 


INDEX  OF  SUBJECTS 


metabolism  in  spasmophiTia,  354; 
requirements  of,  333 

Calomel,  288,  295,  308,  327,  365; 
stools  from,  288 

Calories  (see  also  Energy  metab- 
olism), caloric  value  of  cow's  milk, 
177;  caloric  value  of  human  milk, 
122;  caloric  values,  71,  239;  deter- 
mination of  values,  239;  require- 
ments, 71,  75, 198;  requirements  by 
premature  infants,  72 

Calorimetry,  65 

Carbohydrates,  caloric  values  of,  71; 
decomposition  by  bacteria,  36; 
digestion  and  metabolism  of,  32,  35, 
38;  excessive  amount  of,  42,  54; 
forms  of,  34,  35;  ferments,  32,  130; 
indigestion,  97,  275;  influence  on 
calcium  metabolism,  61,  335,  338; 
influence  on  protein  metabolism, 
37,  54;  respiratory  quotient,  71 

Cascara  sagrada,  327 

Casease,  129 

Casein,  11;  action  of  rennin  on,  162; 
analysis  of,  114;  chemistry  of,  162, 
167;  coagulation  of,  48;  in  cow's 
milk,  167,  215;  curds,  20,  46,  47,  93, 
211,  215,  286;  effect  of  alkalies  on, 
163;  in  human  milk,  113,  215; 
indigestion,  98,  285;  phosphorus 
in,  115;  sulphur  in,  115 

Castor  oU,  287,  295,  300,  308,  327,  365 

Catharsis,  288,  295,  324,  325,  327 

Cereal  diluents,  action  of,  212,  216; 
in  artificial  feeding,  212;  prepara- 
tion of,  235 

Cereals  in  infant  feeding,  247 

Chlorides  in  human  milk,  121;  me- 
tabolism of,  61 

Cholera  bacUlus  in  stools,  86 

Cholera  infantum,  91,  317 

Chvostek's  sign,  354 

Chymosin  {see  Rennin) 

Citric  acid  in  cow's  milk,  170;  in 
human  milk,  122 

Cod-Uver  oU,  290,  338,  359 

Cohc,  289 

Colon,  irrigation  of,  296,  312 

Colostnmi,  103;  amount  of,  136;  ash 
of,  120;  composition  of,  104,  105, 
123;  corpxiscles,  105;  of  cow's  milk, 
157;  hemolysin  in,  133;  human,  104; 
opsonins  in,  133;  protein  of,  106 


Coma  in  infectious  diarrhea,  315 

Constipation,  321;  atonic,  324;  etiol- 
ogy of,  321;  fat  in,  323;  fruit  in,  249 
heredity  in,  321;  mechanical,  322 
in  newborn,  321;  spasmodic,  322 
starch  in,  212,  323;  treatment  of, 
325 

Convulsions  (see  also  SpasmophiKa) 
in  infectious  diarrhea,  316 

Corpus  luteum  a  galactagogue,   125 

Cream,  205,  229 

Cretinism,  322 

Curds,  casein,  20,  46,  47,  93,  211; 
fat,  93;  methods  of  prevention, 
215,  286 

Cystin,  57 

Davidsohn's  reaction,  128 

Dextrin,  35 

Dextrin-maltose  mixtures  in  artificial 
feeding,  206;  in  constipation,  326; 
in  indigestion,  278;  indigestion 
from,  279;  stools  on,  90;  table  of 
various  forms,  206 

Dextrose,  35;  infusions,  310 

Diarrhea,  carbohydrate  in,  37;  cause 
of  acidosis,  363;  dysentery  bacillus 
in,  86;  etiology  of,  49;  fat,  27;  fer- 
mentative, 292;  in  fermentative  in- 

.  digestion,  293;  infectious,  291,  294, 
302;  mineral  salts  in,  62;  nervous 
disturbances,  267;  relation  to  breast 
feeding,  99;  stools  in,  62;  strep- 
tococcus in,  86 

Diastase,  2,  32,  in  stools,  33 

Digestants,  289 

Digestion,  carbohydrate,  32;  dis- 
turbances of,  269;  fat,  20;  gastric, 
6;  intestinal,  19;  leucocytosis  dur- 
ing, 19;  mineral  salts  in,  59;  pan- 
creatic, 14;  physiology,  1;  protein, 
43;  salivary,  2 

Digestive  tract,  diseases  of,  255; 
nervous  distm-bances  of,  267 

Drugs,  excretion  in  hiunan  milk,  126 

Dysentery  bacillus  in  cow's  milk,  176; 
in  stools,  86 

Eggs,  249 

"Eiweissmilch"    (see  Albumin  milk) 
Enemata,  327 

Energy  metabolism,  64;  basal  metab- 
olism, 75;  and  body  surface,  07; 


INDEX  OF  SUBJECTS 


379 


and   body   weight,    68;   effect   of 

exercise,  66;  effect  of  fasting,  66; 

methods  of  computing,  65 
Enterokinase,  16,  44 
Epilepsy,     as     contraindication     to 

nursing,  101 
Erepsin,  16,  18,  45 
Exercise,  effect  on  metabohsm,  66 
Exudative  diathesis,  31 

Fasting,  metabohsm  in,  53,  66 

Fat,  absorption  of,  20,  25;  Babcock 
test  for,  229;  caloric  value  of,  71, 
239;  in  cow's  milk,  169;  curds,  93; 
diarrhea,  27;  digestibihty  of,  21; 
digestion  and  metabohsm,  20; 
effect  on  mineral  metabolism,  61, 
334,  338;  effect  on  nitrogen  me- 
tabolism, 53;  excessive  percentage 
of,  204;  homogenization  of,  203; 
in  hiunan  milk,  115;  indigestion,  97, 
272;  respiratory  quotient  of,  71; 
staining  properties  of,  96;  in  stools, 
23,  24,  25,  26,  27,  30,  95 

Feces,    (see  Stools) 

Feeding,  artificial:  albumin  milk  in, 
222;  alkalies  in,  216;  amount  of 
food  m,  200;  buttermilk  in,  218, 
220;  calcium  in,  332;  caloric  basis 
of,  198,  239;  cow's  milk  in,  194; 
fat  in,  203;  formulsD  for,  231;  gen- 
eral principles,  192;  goat's  milk  in, 
194;  indigestion  from,  271,  273, 
276,  280,  284;  interrelation  of  va- 
rious foods,  219;  intervals  in,  200, 
202;  milk  the  basis  of,  193;  mineral 
salts  in,  219;  mortality  in,  99;  pan- 
creatization  in,  219,  241;  p)ercent- 
age  calculations,  197,  238;  polycar- 
bohydrates  in,  213;  proprietary 
foods  in,  241;  protein  in,  213,  240; 
regularity  in,  200;  relation  to 
rickets,  330;  relation  to  sciu-vy,  343; 
special  milk  preparations  in,  220; 
starch  in,  210,  235;  stools  in,  89; 
sugars  in,  205;  variation  at  dif- 
ferent ages,  202;  variation  of  food 
elements,  203;  whey  mixtures  in, 
215,  236 

Feeding,  breast,  abihty  to  nurse,  100, 
134;  amount  at  single  nursing,  139, 
145;  calcium  in,  332;  causes  of 
failure  to  nurse,  134;  clinical  con- 


siderations and  technique,  134; 
contraindications  to,  101;  difficul- 
ties of,  140;  duration  of  single 
nursing,  139;  in  first  days,  136; 
indigestion  from,  270,  272,  275, 
282;  indirect  method  of,  156;  mor- 
tality in,  99;  normal  results  of, 
143;  regiilarity  in,  138;  relation  to 
digestive  disturbances,  270;  rela- 
tion to  rickets,  330;  relation  to 
scurvy,  343;  relative  frequency  of, 
100;  stools  in,  88;  transmission  of 
immimity  through,  132 

Feeding  during  second  year,  246, 
324 

Feeding  intervals  on  artificial  food, 
200;  on  breast,  138 

Feeding,  mixed,  135,  148 

Feeding,  percentage  (see  Percentage 
feeding; 

Ferments,  amylolytic,  32;  carbohy- 
drate splitting,  32,  130;  fat  spht- 
ting,  20,  130;  gastric,  9,  32,  43;  in 
human  milk,  291;  intestinal,  19, 
33,  44;  in  milk,  129,  130,  131,  181; 
pancreatic,  14,  32,  44;  proteolytic, 
43,  129;  sahvary,  2,  32,  43;  sabol- 
splitting,  131;  in  stools,  33 

Fever,  in  cholera  infantum,  318;  in 
fermentative  indigestion,  294;  in 
infectious  diarrhea,  204,  307;  in 
lactose  indigestion,  277 

Fibrinogen  in  human  milk,  130 

Flatulence,  289 

Fruit  juices,  249,  326,  352 

Galactagogues,  125,  147 
Galactose,  35 
Gastric  (see  Stomach) 
Gastrointestinal  canal,   bacteriology 

of,  77;  diseases  of,  255 
Globuhn  in  cow's  milk,  168;  in  hmuan 

milk,  113 
Glycemia,  36 
Glycocoll,  57 
Glycogen,  35 

Hemolysin  in  himoan  milk,  133 
Hemorrhages  as  contraindication  to 

nursing,  102;  in  scurvy,  342 
Hemorrhoids,  322 
Hirschsprimg's  disease,  322 


380 


INDEX  OF  SUBJECTS 


Hydrochloric  acid,  11,  43,  78 
Hyperpyrexia,  315 

Ice  cap,  315 

Idiosyncrasy  to  cow's  milk,  194 

Immunity,  transmission  through 
milk,  132 

Inanition  fever,  300 

Indigestion,  artificial  food,  271,  273, 
276,  280,  284;  breast  milk,  270,  272, 
275,  282;  carbohydrate,  97,  275; 
casein  curds  in,  48;  classification  of, 
270;  dextrin-maltose,  279;  differ- 
ential diagnosis  of,  294;  etiology  of, 
269;  excessive  food,  270;  excite- 
ment, 268;  fat,  272;  fermentative, 
291;  lactose,  276;  mixed  forms  of, 
98;  protein,  55,  98,  282;  saccharose, 
279;  salts,  286;  starch,  280;  stooLs 
in  carbohydrate,  275,  276,  279,  280; 
stools  in  fat,  282,  283;  stools  in 
fermentative,  293;  stools  in  pro- 
tein, 283,  284,  285;  treatment,  287, 
295 

Infant  mortaUty,  99 

Infantile  atrophy,  28;  anaphylaxis  in, 
50;  nitrogen  retention  in,  55 

Insanity  as  contraindication  to  nurs- 
ing, 101 

Intestinal  fermentation,  222,  291 

Intestines,  antiferments  of,  44;  atresia 
of,  321;  bacteriology  of,  36,  38,  79, 
83;  changes  in  indigestion,  292; 
changes  in  infectious  diarrhea,  303; 
digestion  in,  36;  endogenous  infec- 
tion of,  80;  ferments  of,  33; 
hemorrhage  of,  94;  length  of,  18; 
mineral  salts  in,  59;  nervous  dis- 
turbances of,  267;  reaction  of,  18; 
secretions  of,  18;  small,  18 

Intussusception,  differential  diagno- 
sis of,  306;  stools  in,  94 

Inunctions,  290 

Invertin,  18,  19,  33 

Iron  in  human  milk,  121;  metabolism 
of,  60 

Jackson's  membrane,  322 
Jaundice,  efifect  on  human  milk,  128 

Kidneys  in  acidosis,  363,  365;  in 
fermentative  indigestion,  292;  in 
infectious  diarrhea,  303 


Laboratories,  milk  {see  Milk  labora- 
tories) 

Lactalbumin,  57;  in  cow's  milk,  168; 
in  human  milk,  113 

Lactase,  19,  33 

Lactic  acid,  78 

Lactoglobulin,  168 

Lactose,  in  artificial  feeding,  205; 
in  cow's  milk,  169;  effect  on  gastric 
motiUty,  35;  in  human  milk,  119; 
indigestion  from,  209,  276;  toler- 
ance of,  41 

Laryngismus  stridulus,  354 

Laxatives,  327;  abuse  of,  324 

Lecithin  in  cow's  milk,  169;  in  hiunan 
milk,  119,  121 

Lemon  juice,  346,  352 

Leucocytosis:  in  fermentative  in- 
digestion, 293;  in  infectious  di- 
arrhea, 305 

Levulose,  35 

Lime  water,  12, 165, 217;  action  of,  12 

Lipanin,  339 

Lipase,  10,  14 

Lipemia,  23,  365 

Liver,  16;  in  fermentative  indigestion, 
292;  glycogenic  function  of,  35;  in 
infectious  diarrhea,  303;  iron  in,  60; 
weight  of,  16,  17 

Lysin,  57 

Magnesia,  "milk  of,"  288,  308,  327 

Magnesium:  metabolism  of,  60 

Magnesium  sulphate,  359 

Malnutrition:  constipation  in,  324 

Maltase,  19,  33 

Malted  foods,  243 

Maltose,  35;  in  artificial  feeding,  207; 

indigestion  from,  279;  stools  from, 

90 
Marasmus  {see  Infantile  atrophy) 
Meat,  249 
Meat  broths,  248 
Meconium,  88;  bacteriology  of,  81; 

ferments  of,  33,  44;  retention  of, 

137;  toxic  products  of,  298 
Megacolon,  322 
Melena  neonatorum,  300 
Meningitis,  300,  307 
Menstruation,  effect  on  human  milk, 

127;  relation  to  weaning,  150 
Metabolism,    1;  basal,   64,   75;  and 

body  surface,  67;  carbohydrate,  38; 


INDEX  OF  SUBJECTS 


381 


energy,  64;  exercise  in,  66;  fasting, 
66;  fat,  20,  24;  gaseous,  64;  mineral 
68;  in  newborn,  74;  protein,  53; 
in  scurvy,  348;  in  starvation, 
75 

Milk,  certified,  189;  coagulation  of, 
48;  comparative  absorption  of  pro- 
teins, 51;  composition  in  different 
animals,  172 

Milk,  cow's,  acidity  of,  159;  action  of 
rennin  on,  161;  alexins  in,  181; 
anaphylaxis  to,  50;  appearance  of, 
158;  bactericidal  power  of,  181; 
bacteriology  of,  175,  181;  calcium 
in,  332;  caloric  value  of,  177; 
casein  in,  160,  167,  215;  certified, 
189;  chemistry  and  biology  of, 
157,  165.;  citric  acid  in,  170;  co- 
agulation of,  159;  colostrum  of, 
157;  comparison  with  hvunan,  195; 
comparison  of  raw  and  pasteurized, 
182;  comparison  of  various  breeds, 
166,  196;  condensed,  243;  effect  of 
freezing  on,  171;  effect  of  heating 
on,  179,  182,  186,  216,  323,  336, 
344;  extractives  in,  168;  fat  in, 
116,  168,  203,  229;  fatty  acids  in, 
118;  ferments  in,  181;  idiosyncrasy 
to,  50,  194;  lactalbumin  in,  168; 
lactoglobulin  in,  168;  lactose  in, 
169;  lecithin  in,  169;  microscopy 
of,  158;  mineral  salts  in,  169,  219; 
mixed,  196;  modification  of,  149, 
195;  nitrogenous  bodies  of,  165; 
pancreatization  of,  241;  paracasein 
in,  167;  pasteurization  of,  179,  186; 
phosphorus  in,  122;  precipitation 
with  acids,  159;  preservatives  in, 
177;  proteins  of,  215;  reaction  of, 
158;  smell  of,  158;  solids  of,  229; 
specific  gravity  of,  158;  steriUza- 
tion  of,  179;  stools  from,  89;  taste 
of,  158;  vitamins  in,  349;  whey  of, 
168,  215 

Milk,  fat  free,  230 

Milk,  goat's,  173,  194 

Milk,  home  modification  of,  226; 
calculation  of  formtdae,  231;  cal- 
culation of  starch  mixtures,  235; 
calculation  of  whey  mixtures,  236; 
composition  of  materials  in,  229; 
determination  of  caloric  value,  239; 
determination  of  percentages,  238; 


determination  of  protein  content, 
240;  pancreatization  in,  241 

Milk,  human,  abnormal  types  of,  142, 
146;  agglutinins  in,  133;  albumin- 
ous bodies  in,  113;  alcohol  in,  127; 
analysis  of,  143;  antibodies  in,  132; 
antitoxin  in,  132;  bactericidal  sub- 
stances in,  133;  bacteriology  of, 
106;  beriberi  in  relation  to,  128; 
bile  in,  128;  calcium  in,  121,  332; 
caloric  value  of,  122;  casein  in,  113, 
114;  characteristics  of,  107;  chem- 
istry of,  103,  111,  123,  172;  chlo- 
rides in,  121;  citric  acid  in,  122; 
coagulation  of,  110,  111;  color  of, 
107;  comparison  with  cow's,  195; 
diet  in  relation  to,  124,  146;  dif- 
ferentiation of,  128;  elimination  of 
drugs  in,  126;  estimation  of  amount 
of,  145;  fat  in,  115,  116,  117,  118; 
fatty  acids  in,  118;  ferments  in,  129; 
foreign  bodies  in,  126;  globulin  in, 
113;  hemolysin  in,  133;  influences 
on  secretion  of,  127;  iron  in,  121; 
lactalbumin  in,  113;  lactose  in,  119; 
lecithin  in,  119;  menstruation  in 
relation  to,  127;  microscopy  of,  107; 
mineral  salts  in,  119,  120,  219; 
modification  of,  146;  nephritis  in 
relation  to,  128;  nervousness  in 
relation  to,  127;  nitrogenous  bodies 
in.  111,  112,  113,  114;  nuclein  in, 
119;  opaUsin  in,  114;  opsonins  in, 
133;  phosphorus  in,  115,  121; 
pigments  of,  117;  preservation  of, 
156;  proteins  of.  111,  112,  113, 114, 
215;  quaUty  of,  142;  quantity  of 
secretion,  108,  109;  reaction  of, 
108;  residual  nitrogen  of,  113; 
"running  in"  of,  134;  specific 
gravity  of,  108;  stools  from,  88; 
toxins  in,  132;  transmission  of 
toxins  and  immunity  through,  132; 
uremia  in  relation  to,  128;  varia- 
tions in  composition  of,  123; 
viscosity  of,  122;  vitamins  of,  349; 
whey  of,  215 

Milk,  modified,  prescribing  of,  225 

Milk,  skimmed,  230,  233;  stools 
from,  89 

Milk  laboratories,  226 

Milk  poisoning,  182 

Milk  sickness,  177 


382 


INDEX  OF  SUBJECTS 


Milk  sugar  (see  Lactose) 

Mineral  salts,  in  cow's  milk,  169; 
in  human  milk,  119,  120;  indiges- 
tion from,  219,  286;  influence  of 
food  elements  on  metabolism  of, 
61;  influence  on  calcium  metab- 
olism, 335;  loss  in  fat  indigestion, 
273;  metabolism  of,  58;  metabo- 
lism in  scurvy,  348;  metabolism  in 
spasmophilia,  356;  relation  of 
oedema  to,  62;  utilization  of,  59 

Moro's  reaction,  128 

Mouth,  bacteriology  of,  1,  77;  care  of, 
141;  deformities  in  relation  to 
nursing,  140;  digestion  in,  2;  fer- 
ments of,  2;  reaction  of,  1 

Mucus,  in  stools,  93 

Nephritis,  as  cause  of  acidosis,  363; 
effect  on  human  milk,  128 

Nervous  irritability  in  infectious  di- 
arrhea, 315;  in  protein  indigestion, 
284 

Nervousness,  effect  on  human  milk, 
127,  148 

New-born  infant,  constipation  in, 
321;  intestinal  toxemia  in,  298; 
metabolism  of,  74 

Nipple  shields,  141 

Nipples,  care  of,  140 

Nitrogen  (see  Protein) 

Nuclein  in  human  milk,  119 

Nucleon  in  human  milk,  121 

Nursing,  amount  at  single,  139,  145; 
causes  of  failure,  134;  difficulty  in 
technique,  140;  duration  of  single, 
139;  intervals  between,  138; 
method  of,  138,  141;  during  night, 
138;  regularity  of,  138 

Nutrition,  diseases  of,  329 

CEdema,  relation  of,  to  salts,  62;  in 

scurvy,  342 
Oils,  inunction  of,  290 
Olive  oil,  28;  in  constipation,  327 
Opalisin  in  human  milk,  114 
Opium,  313 

Opsonins,  in  human  milk,  133 
Orange  juice,  247,  352 
Ovary,  influence  on  breast,  126 
Oxydase,  in  milk,  131 

Pancreas,   14;  ferments  of,  32,  44; 


influence  on  glycogen  absorption, 
35;  mineral  salts  in,  59;  secretions 
of,  14;  size  of,  14,  15 

Pancreatization  of  food,  219,  241 

Paracasein,  167 

Paratyphoid  bacillus  in  stools,  86 

Parathyroid  glands,  in  spasmophilia, 
354,  357 

Parotid  gland,  2 

Pasteurization  of  milk,  179 

Pepsin,  9,  13,  43;  in  milk,  129 

Peptonization  of  food,  219,  241 

Percentage  feeding,  197;  calculations 
in,  231,  238 

Peroxidases,  131 

Phosphorus,  359;  in  human  milk,  121; 
metabolism  of,  60,  336,  362;  in 
rickets,  339 

Pineal  extract,  as  galactagogue,  125 

Pituitary  extract,  as  galactagogue, 
125 

Placental  extract,  as  galactagogue, 
125 

Polycarbohydrates,  213 

Posture,  influence  on  digestion,  9 

Potassium,  influence  on  calcitun  me- 
tabolism, 336;  metabolism  of,  61 

Potato,  249,  352 

Pregnancy,  in  relation  to  weaning, 
150 

Premature  infant,  amount  of  food  for, 
253;  caloric  needs  of,  251;  char- 
acter of  food  for,  252;  extrabuccal 
feeding  of,  253;  feeding  intervals, 
251;  human  milk  for,  250;  inability 
to  nurse,  102;  metabolism  of,  250; 
methods  of  feeding,  253;  secretions 
of,  250;  water  need  of,  253 

Proctoclysis,  367 

Proprietary  foods,  241;  relation  to 
scurvy,  343 

Prostration,  316,  317 

Protein,  absorption  of,  46;  in  artificial 
feeding,  213;  caloric  value  of,  71, 
239;  determination  in  modified 
milk,  240;  digestion  of,  43;  exces- 
sive amoimt  of,  214;  excretion  of, 
52,  53;  in  human  milk,  111,  112, 
113,  114;  indigestion,  98,  282;  in- 
fluence of  carbohydrates  on,  37; 
influence  on  calcium  metabolism, 
334;  metabolism  of,  43,  53;  need  of 
infant,  56,  192,  214;  relative  value 


INDEX  OF  SUBJECTS 


383 


of,  57;  respiratory  quotient  of,  71; 
sensitization  to,  51;  sparing  of, 
37,  38,  54;  utilization  of,  64,  65; 
vegetable,  214 

Protein  milk  (see  Albumin  milk) 

Proteolysis,  45,  46 

Ptyalin,  2 

Puerperal  eclampsia,  as  contraindica- 
tion to  nursing,  102 

Purgatives,  327 

Pus,  in  stools,  94 

Pylorus,  action  of,  8;  spasm  of,  20, 
255,  262;  stenosis  of,  256,  259 

Pyocyaneus  bacillus,  302 

Rectum,  imperforate,  321 

Reductase,  131 

Rennin,  10,  13,  43;  action  on  boiled 
milk,  216;  action  on  cow's  milk, 
161;  action  on  human  milk,  110; 
effect  of  lime  water  on,  165;  effect 
of  sodium  citrate  on,  164 

Respiratory  quotient,  70 

Rickets,  329;  chemistry  of,  334;  con- 
stipation in,  324;  etiology  of,  330; 
experimental,  331;  heredity  in,  330; 
infectious  origin  of,  330;  internal 
secretions  in,  331;  metabolism  in, 
332;  pathology  of,  329;  phosphorus 
metabolism  in,  336;  relation  to 
heated  milk,  184;  treatment  of,  337 

Saccharose,  35;  in  artificial  feeding, 
210;  indigestion,  279 

Saliva,  amoimt  of,  3;  ferments  of,  32, 
43 

Salivary  glands,  1 

Salt  solution,  314 

Salvarsan,  excretion  in  human  milk, 
127 

Scarlatina,  transmission  by  cow's 
mUk,  176 

Sclerema,  318 

Scurvy,  247;  etiology  of,  343;  ex- 
perimental, 345;  metabolism  in, 
348;  pathology  of,  341;  relation  to 
heated  milk,  184;  treatment  of, 
351;  vitamins  in,  349 

Secretin,  15,  44 

Sedatives,  316 

Sellards'  test,  364 

Senna,  327 

Sepsis  in  newborn,  300 


Sleep,  of  breast  fed,  144 

Soap  enema,  327 

Soap  stools,  25,  26,  27,  323 

Sodium,  influence  on  calcium  metab- 
olism, 335;  metabolism  of,  61,  287 

Sodium  bicarbonate,  367;  action  of, 
12;  in  artificial  feeding,  218 

Sodium  chloride,  pyrogenic  effect  of, 
40,41 

Sodium  citrate,  a,ctlon  of,  12;  in 
artificial  feeding,  218;  effect  on 
rennin,  164 

Sodium  phosphate,  327 

Spasmophilia,  calcium  metabolism  in, 
355;  in  fat  indigestion,  274;  hered- 
ity in,  354;  parathyroids  in,  357; 
treatment  of,  358 

Starch,  35;  in  artificial  feeding,  210; 
caloric  value  of,  239;  as  cause  of 
constipation,  212,  digestion  of,  2, 
3;  excessive  amount  of,  212;  in- 
digestion from,  97,  280;  mixtures, 
235;  as  protective  coUoid,  211; 
in  stools,  94,  95 

Starvation,  acidosis  in,  363;  metab- 
olism in,  75;  stools  in,  52,  90 

Steapsin  (see  Lipase) 

Stimulants,  314,  316,  319 

Stomach,  3;  absorption  in,  13;  acidity 
of,  12;  air  in,  9;  bactericidal  powers 
of,  78;  bacteriology  of,  78;  butyric 
acid  in,  78;  capacity  of,  4;  cathe- 
terization of,  288;  digestion  in,  6; 
dilatation  of,  263;  ferments  of,  32; 
growth  of,  3;  hydrochloric  acid  in, 
11;  influence  of  posture  on,  9; 
lactic  acid  in,  78;  motihty  of,  7; 
nervous  disturbances  of,  267;  posi- 
tion of,  3;  pyloric  spasm,  255; 
pyloric  stenosis,  259;  secretions  of, 
9 

Stools,  87;  abnormal  constituents  of, 
93;  animal  food,  90;  of  artificially 
fed,  89,  bacteriology  of,  81,  85,  96; 
black,  93;  blood  in,  94;  blue,  93; 
of  breast-fed,  88,  143;  buttermilk, 
90;  calcium  in,  334;  in  carbohy- 
drate indigestion,  275,  276,  279, 
280;  in  casein  indigestion,  285; 
in  cholera  infantum,  317;  color  of, 
92;  cow's  milk,  89;  curds  in,  48, 
93;  dextrin-maltose,  90;  fat  in,  23, 
24,  25,  26,  27,  30,  92,  95,  97;  in  fat 


384 


INDEX  OF  SUBJECTS 


indigestion,  272,  273;  in  fermenta- 
tive indigestion,  293;  ferments  of, 
33,  44;  gray,  92;  green,  92;  in  in- 
digestion, 97;  in  infectious  di- 
arrhea, 303;  in  intusstisception,  306; 
membranes  in,  94;  microscopic 
examination  of,  94;  mucus  in,  91, 
93;  nitrogen  in,  52;  odor  of,  91; 
phosphorus  in,  336;  pink,  93;  in 
protein  indigestion,  283,  284,  285; 
pus  in,  94;  reaction  of,  91;  salts  in, 
27;  skimmed  milk,  89;  starch  in, 
94,  95,  97;  from  starch,  89;  in 
starvation,  52,  90;  in  stenosis  of 
pylorus,  264;  sugar  in,  36;  whey,  89; 
white,  92 

Submaxillary  glands,  2 

Sucking,  mechanism  of,  1 

Sugars,  absorption,  limits  of,  41; 
ia  artificial  feeding,  205;  caloric 
value  of,  239;  excretion  of,  38,  39; 
fever,  206;  forms  of,  35;  indigestion 
from,  276;  intestinal  fermentation 
of,  222;  intoxication  by,  40,  41; 
laxative  action  of,  38,  206 

Sulphm",  metabolism  of,  61,  362; 
metabolism  in  sciu*vy,  348 

Superoxidase,  131 

Suppositories,  325,  327 

Syphilis,  transmission  by  breast  milk, 
107 

Tenesmus,  treatment  of,  313 
Tetany,     354,     experimental,     355; 

parathyroid,  357 
Thymus,  in  rickets,  331 
Thyroid,    in    constipation,    321;    in 

rickets,  331 
"Top  mUk,"  205,  230 
Toxemia,  intestinal,  298;  acidosis  in, 

365;  in  infectious  diarrhea,  314 
Toxins,  transmission  through  human 

milk,  132 
Trembles,  177 
Trousseau's  sign,  354 
Trypsin,  10,  14,  44;  in  milk,  129 
Trypsinogen,  16,  44 
Tryptophan,  57 


Tubercle  bacillus,  in  cow's  milk,  176; 

in  stools,  86 
Tuberculosis,  as  contraindication  to 

nursing,  101 
Tuberculous  peritonitis,  30 
Tugendreich's  reaction,  129 
Typhoid  bacillus,  in  cow's  milk,  176; 

in  stools,  85 

Umikoff's  reaction,  128 
Uremia,  effect  on  human  milk,  128 
Urine,  acetone  bodies  in,  363;  cal- 
cium in,  334;  in  cholera  infantum, 
318;  in  fermentative  indigestion, 
293;  in  infections  diarrhea,  305; 
nitrogen  in,  53 

Vasomotor  paralysis,  318 

Vegetables,  in  constipation,  326;  in 
diet,  249;  in  scurvy,  346 

Vitamins,  56,  349 

Vomiting  in  acidosis,  364;  in  carbo- 
hydrate indigestion,  275;  in  casein 
indigestion,  285;  in  cholera  infan- 
tum, 317;  habitual,  264;  in  indiges- 
tion, 288;  in  infectious  diarrhea, 
315;  in  lactose  indigestion,  277; 
in  nervous  disturbances,  267;  after 
nursing,  142;  in  pyloric  spasm,  256; 
ia  pyloric  stenosis,  260;  whey 
mixtures  in,  216 

Weaning,  149;  age  for,  151;  diet  after, 
246;  indications  for,  149;  menstrua- 
tion in  relation  to,  150;  pregnancy 
in  relation  to,  150;  in  summer,  151; 
technique  of,  151 

Wet-nurses,  general  considerations, 
153;  management  of,  155;  methods 
of  procuring,  156;  protection  of, 
154;  qualifications  of,  154 

Whey,  57;  chemistry  of,  168;  of  cow's 
milk,  215;  of  hiunan  milk,  215; 
indigestion  from,  284;  preparation 
of,  238;  protein  of,  162,  215;  stools 
from,  89 

Whey  mixtures,  215,  236;  for  pre- 
mature infants,  252 


Printed  in  the  United  States  of  America 


ILQ; 


